News Category: Wrist

If you are over 65 years old and you break your wrist in Great Falls, Montana, will you get the same treatment as if you are over 65 and the injury occurs in California or Florida or Colorado? Researchers from Dartmouth Medical Center noticed that there aren’t a lot of studies on the optimal treatment for distal radial fractures. So, they used Medicare records to answer a few questions about the current state of affairs.

First, how often does this type of injury occur? A distal radial fracture refers to the end of the radius (one of two bones in the forearm) at the wrist. Most often these fractures occur as a result of a fall on an outstretched arm. According to Medicare records, 125 out of every 10,000 people on Medicare have an injury of this type.

Older adults with balance problems and osteoporosis (brittle bones) seem to be the group with the largest rate of fractures in general. Wrist fractures of the distal radius occur in white women most often. In fact, women are almost five times more likely than men to break their wrists. White women are twice as likely as non-whites to fracture their wrists. Most of this was due to the higher rates of osteoporosis in white women.

The next question is: once a fracture is identified, how is it treated? There are three basic types of fracture treatment including 1) putting a cast on the arm, 2) slipping a wire through the skin to hold the bones together, a procedure called percutaneous fixation, or 3) open surgery to repair the fracture with metal plates and/or screws. This last category of surgery is referred to as open reduction and internal fixation (ORIF).

And the third question is: does treatment vary depending on where you live, how old you are, your race, or sex? They answered all of these questions by analyzing a sample of Medicare Part-B claims across the United States.

Since treatment is billed by a procedural code, they could use these codes to tell who had what kind of treatment. Patients treated by their primary care physicians in an outpatient (clinic) setting and those who were treated in a hospital or emergency department were all included. Over 300 hospital referral regions were identified by zip code and used to map out regions in the U.S. Colored maps were presented in the article to help the reader see where the largest numbers of patients were located and then what kind of treatment was given by region.

It turns out that the rate of wrist fracture goes up with age. The oldest group (over age 80) had the highest rate of wrist fractures. Most patients (83 per cent) could be treated nonoperatively. The remainder had surgery. Older patients are less likely to have surgery. And the rate of surgery increased (doubled) during the time of this study (between 1998 and 2004).

But the most striking finding was that the kind of treatment you might receive for a wrist fracture varied greatly depending on where you lived. Nonoperative care was more common in places like Kentucky (compared to California). Open surgery varied from 0.4 per cent in Pennsylvania to 25 per cent in Great Falls, Montana. Some of the differences noted were likely due to whether patients lived in an area where there is a high density of orthopedic surgeons and the type of hospitals available (e.g., teaching hospitals versus rural hospitals).

The biggest factor on whether or not surgery was done was the presence of comorbidities (other health problems). The more compromised the patients health was, the less likely they would have surgery. Race did not seem to be a major factor in the choice of treatment. Concern about cosmetic appearance might have had an effect on the type of operation performed.

One other finding from this study that mimics previous studies on ankle injuries is the presence of a fracture belt. Fracture belt refers to a higher number of fractures in a geographical region, specifically the northeastern section of the United States. Several factors may be linked with this pattern of distribution.

For example, weather conditions in that area with more ice and snow than in other places could be an important regional difference. Limited exposure to sunlight resulting in higher levels of osteoporosis and lack of water with fluoride in it could contribute to the higher level of osteoporosis-linked fractures. And possibly more involvement in sports activities may affect the rate of falls.

The authors conclude that although they were able to conduct a comprehensive overview on the incidence and type of treatment for wrist fractures, they still couldn’t really say why there is such a difference in how it’s treated from one region to another. There could be a wide range of variables such as physician training, cultural beliefs, or even personal or even religious preferences.

More studies are needed to determine the most appropriate care for distal fractures in this age group. Using the Medicare database was a helpful place to start, but it does not include information about how the injury occurred, the functional status of patients, or even the type of fracture present.

This is the first study to compare the results of open surgery versus arthroscopic surgery for septic arthritis of the wrist. The procedure was an irrigation and débridement. That means once the surgeon accessed the area of infection (either through an open incision or arthroscopically), saline fluid was used to flush the area clean (irrigation). In a second step (débridement), any fluid and any loose tissue or fragments of cartilage were removed.

Septic arthritis is the invasion of a joint by an infectious agent that produces arthritis. It can affect any of the joints in the body but has a tendency to settle in the large joints. This includes the hip, knee, and shoulder. The infectious agent starts someplace else (often a skin infection called cellulitis or from a urinary tract infection. It travels to the joint directly by local spread or through the blood system.

Risk factors for septic arthritis include joint replacement, cancer, kidney failure, or other chronic diseases. For example, chronic alcoholism, diabetes, rheumatoid arthritis, or other connective tissue disorder have been linked with septic arthritis. Taking medications that can suppress the immune system (e.g., prednisone, other immune modulators such as current or recent chemotherapy) is another potential risk factor for developing septic arthritis.

Septic arthritis of the wrist doesn’t happen very often. At the Mayo Clinic (where this report is from), they treated 40 wrists over a 10-year period of time. That accounts for why published studies are few and far between on the management of septic wrist problems. A typical patient profile was age over 60, multiple comorbidities (other health problems), and immunosuppression. In most cases, the infection was cultured and found to be a staph infection.

Surgeons have successfully treated septic arthritis of these larger joints with arthroscopic irrigation and débridement. Open incision surgery remains the standard for the wrist. Both surgical techniques (open and arthroscopic) are described in detail to help the reader understand the potential advantages and disadvantages of each approach.

Arthroscopic surgery allows the surgeon to make tiny incisions that don’t endanger the ligaments or cartilage. There is less pain and no open, draining wound. On the other hand, an open incision gives the surgeon a full view of the wrist anatomy making it easier to avoid cutting blood vessels or damaging other tissues such as nerves.

The authors cast a wide net in terms of looking for differences in treatment effects between the two procedures. They included lab work such as white blood-cell count and sed rate (both are measures of inflammation) and identification of the bacterial content of the culture.

They also kept track of how many days patients were in the hospital, how long they took antibiotics, any record of deaths, and the total number of procedures required until the all clear bell was sounded indicating successful treatment of the joint infection. Pain levels, wrist range-of-motion, and load tolerated through the wrist were measured for patients in both groups and compared.

In general, the patients who developed septic arthritis were in poor health with multiple problems and taking medications that suppressed the immune system. The most common medications of this type were steroids and chemotherapy. Half the total group had septic arthritis in another joint (sometimes in several other joints). The cause of the infection was usually staphylococcus aureus, otherwise more commonly known as a staph infection.

A significant number in each group required more than one irrigation and débridement procedure before the infection was stopped. Most of the time, the procedure only had to be repeated one time for patients in either group. But in some patients (again, in both groups), as many as four or five repeat procedures were required.

Patients with multiple infected joint sites were much more likely to need a second operation. Length of hospital stay increased dramatically when repeat procedures were performed. When comparing patients who only had one septic joint (wrist), the length of hospital stay for arthroscopic surgery was much less (two to 12 days) compared with open surgery (seven to 34 days).

Intravenous antibiotics are an important post-operative treatment for septic arthritis. Comparing the arthroscopic group to the open group, the arthroscopic group had one week less of antibiotics. That is actually quite a cost savings. On the down side of things, there were a fair number of deaths in both groups due to sepsis and multisystem organ failure. Sepsis refers to total body infection.

The authors observed within their own study a general trend toward more arthroscopies for the treatment of septic wrist arthritis as time went by. They found that by the end of the study that patients with isolated (just wrist) septic arthritis treated arthroscopically had fewer operations and fewer days in the hospital. They concluded that this treatment approach is just as successful and more cost effective compared with the same kind of surgery done as an open procedure.

Right now, most doctors prefer to fix an acute scaphoid fracture (fracture of the small bone on the thumb side of the wrist, where the wrist bends) with surgery if the break moves the bones, or displaces them. The chances of the bones not joining or not fusing properly are higher, so surgery’s role is fairly obvious. But, in breaks where the bones aren’t displaced isn’t as clear cut when it comes to treatment, although surgeons who favor it say that the patients can return to their regular life more quickly and the bones still heal better with surgery.

The authors of this study examined six published randomized controlled trials that compared treatment with a cast (immobilization) with surgery. The researchers looked at the x-rays of the wrist bones, but were hampered by there not being any computer tomography scans (CT scans) and only three of the six studies reported when the bones joined or fused (called “time to union”).

Five of the six studies found that the union rates were high for both groups. One study, led by Dias, found that there was a difference between the two groups and union rates. They found that 10 of the 44 casted wrists did not fuse, something that didn’t happen in any of the 44 wrists that had received surgery. When looking at recovery time, one study that did report time to union, led by McQueen, found that the surgical patients recovered more quickly than the casted patients. However, another study led by Adolfsson didn’t see the same results at all.

Grip strength is one way of measuring how well a wrist has healed. Most of the studies reported that there was no difference in grip strength between the two groups during their final assessment of the patients, but earlier in the study (at eight and 16 weeks), the surgery patients did have, on average, a stronger grip strength than the casted patients. All studies had similar return-to-work rates although, patients who did manual labor returned to work more quickly if they had had surgery.

When considering costs, casting is significantly less expensive than surgery but, interestingly, only in non-manual labor workers where the cost was one-third of the surgery cost. For manual workers, the cost was still cheaper for surgery, but the difference wasn’t as wide as with the non-manual workers.

Treatments always have the risk of complications. With casting, complications include stiffness and weakness after the cast is removed. With surgery, complications include infection (common to all types of surgery), chronic regional pain syndrome, scar-related complications, hardware problems (breaking, movement, visible), and osteoarthritis.

The authors wrote that the six studies they examined had several shortcomings. The lack of CT scanning made it more difficult to see the fracture and healing and they felt that perhaps not all the fractures actually fell into the non-displaced category. The x-rays can’t be depended on to accurately diagnose a scaphoid fracture and when it healed. As well, since most people who break the scaphoid are young, mobile and independent, many are likely not to return for follow ups if they feel that they’ve healed sufficiently.

They also felt that the return to work measure wasn’t a precise or objective measurement because of the way that different work environments judge if someone is able to return or not. The example in this article is the U.S. Navy – someone in the navy who has a cast isn’t allowed to return to active duty, which would delay the calculation of time for return to work.

Complications during surgery are sometimes the result of surgeons who don’t perform the particular surgery frequently. Inexperience could result in higher complication rates for the surgical scaphoid repairs.

In conclusion, the authors feel that there needs to be reliable and valid methods to diagnose both the fracture, bone displacement, and union of the bones, such as using CT scanning. To be able to determine whether surgery or casting is best, a large, multicenter trial is needed.

The scaphoid bone, the small wrist bone at the base of the thumb, is easily broken, particularly if someone falls on an outstretched hand. Treatment of such a fracture is debatable among some surgeons as some prefer to do casting, while others prefer surgery for optimal healing. For casting, it’s estimated that 90 percent to 95 percent of scaphoid waist fracture are healed by cast in about three months. However, for some patients, the three month wait isn’t acceptable, often because it hampers their return to work. To encourage faster healing, some surgeons will do surgery to insert a screw, to stabilize the bone.

The pros of casting include that it is safe and inexpensive. The major con is that recovery time can be long. The authors of this article looked at three studies that looked at casting for scaphoid waist fractures. One, led by Gellman, followed two randomized groups of patients: those who had an above elbow thumb spica cast for a nondisplaced (bones haven’t moved) fracture and those who had a below elbow spica thumb cast. A spica thumb cast holds the thumb in a “hitchiker’s” position as it heals. The researchers felt that the above elbow cast could help protect the thumb better than the shorter one. The patients who had the above elbow spica cast were switched to a below elbow spica cast after six weeks and the researchers found that these patients had a quicker healing time (9.5 weeks) over patients who had only the below elbow spica cast (12.7 weeks).

Another study, led by Clay, looked at 392 fractures and the patients were divided into those who had below elbow casts that immobilized the thumb up past the joint at mid-thumb (the interphalageal joint and those that didn’t involve that joint. There appeared to be no difference in the results of the two groups; both had a 10 percent non-union rate of bones that had broken clear across. Finally, a third study, by Hambridge and colleagues, randomized patients to casts that either placed the wrist bone with a slight extension (outward position) or with it flexed inward a bit, both with the thumb free. There didn’t seem to be any difference in healing, but patients whose thumbs had been flexed had more problems getting the thumb straightened out afterwards.

Six other studies looked at surgery for management of the fractures. Study 1 by Saeden and colleagues, looked at 62 fractures, half of which were casted and half underwent surgery with hardware to stabilize the bone. So-called blue collar workers were off work for about six weeks if they had surgery, 15 weeks if they were casted, although all patients -casted or operated – had successful treatment. However, those who had surgery had a higher rate of developing osteoarthritis in the area later 12 years later.

Study 2, by Bond and colleagues, looked at 25 military personnel with fractures. They either were casted with long arm casts with the thumb free or the wrist operated on to insert a screw. There was no difference in the healing and outcomes, but those who had surgery did return to work more quickly. In Study 3, by Adolfsson, 28 patients were assigned to casting for 10 weeks and 25 patients had a screw inserted. Again, there was no difference in outcome between the two groups, with the exception of motion. Those who had surgery had better motion 16 weeks after the accident than those who were casted.

In Study 4, Dias and colleagues looked at 88 patients who were divided into eight weeks of casting wit the thumb free or surgery. Although there was a difference at eight and 12 weeks after surgery (better findings with the surgery group), the overall long-term outcome was the same for both. In Study 5, McQueen and colleagues found yet again the same results among 60 patients although the casted patients did take longer to return to their previous sports and work activities. Finally, in Study 6, Vinnars and colleagues also found the same results in their study of 83 fractures.

Cost-wise, the type of treatment does may a difference. The surgery provided better life quality during healing than did casting and was cheaper overall. Although the surgery itself was more costly than casting, those who were casted lost more work days and productivity than those who had surgery. However, if patients had functional casts and could return to work with the cast, the costs would turn out to be more for surgery, as those who returned to work with only casting could return more quickly.

The authors concluded that there doesn’t appear to be a clear-cut superiority of one treatment over another when managing this type of fracture. The bones healed fairly equally in rate (about 90 percent) regardless of the procedure. To be able to be more specific about which patients (age, type of work, type of surgery, type of cast, as well as results over short, medium, and long term, would need to be assessed through a large multicenter trial.

This is the first study of arthroscopic descriptions of what happens inside the wrist affected by gout. Some interesting, new findings are reported.

Gout is an inflammatory process that is known to affect the articular cartilage and subchondral bone. The articular cartilage is the thick, fibrous covering or lining of the joint. Subchondral bone is the first layer of bone just under the cartilage.

Gout is considered a metabolic form of arthritis. The body produces too much uric acid (a condition called hyperuricemia). Hyperuricemia causes urate crystals to form and get dumped in the bloodstream. The crystals of monosodium urate (MSU) or uric acid are then deposited on the articular cartilage of joints, tendons and nearby tissues.

People with gout experience painful attacks of arthritis when these crystal deposits build up forming pockets of crystals or nodules called tophi (singular form: tophus). The body sets up an inflammatory response to these crystals. The big toe is affected most often, but other joints such as the wrist (which is the focus of this study) can become swollen and painful.

Over time, the acute inflammatory response turns into a chronic condition. The articular cartilage is worn away right down to the bone. Bone loss can also occur. Until now, it was always thought that the joint was the main area affected. But this study of seven patients examined arthroscopically offers some new insight into the damage that can occur in the other soft tissue structures.

Seven men with previously diagnosed gout came to the physician with new onset of wrist pain on one side. There was pinpoint pain and tenderness over the scapholunate ligament. Testing the integrity of that particular ligament, the surgeons found a positive scapholunate ligament shift test. This indicates wrist instability because the ligament isn’t holding the bones steady. The two bones shift or move more than they should.

Everyone in the study was treated conservatively at first. Care consisted of activity modification, splinting, antiinflammatory medications, and steroid injections. When all of those attempts failed, X-rays and MRIs were ordered. X-rays showed that five of the seven patients had scapholunate advanced collapse (SLAC). That is to say, the cartilage of the two wrist bones (the scaphoid and the lunate) had worn away. The bones started to deteriorate and collapse.

Arthroscopic surgery was scheduled to find out what was causing the problem. Inserting a long, thin probe with a tiny TV camera on the end into the wrist gave the surgeons a clear view of what was going on. They could clearly see urate crystals deposited on and around the scapholunate ligament. The ligament was disrupted (torn). In some cases, the tear was mild. In other patients, the tear was large enough that the surgeon could pass the scope through the gap.

Other ligaments such as the lunotriquetral ligament, and the triangular fibrocartilage complex were also damaged. There were no crystal deposits seen in the triangular fibrocartilage complex (TFCC) of patients– even though there were tears of this soft tissue structure. The TFCC is an important stabilizing structure in the wrist.

They took tiny snips of the synovium and scraped crystal deposits off the ligaments and sent them to the lab for analysis.

From this study, it looks like urate crystals can and do attach to the scapholunate ligament of the wrist. Damage of the tissue leads to disruption of the ligament under less than normal loads. Collapse of the scapholunate bones develops — not from erosion of the cartilage, which is the typical effect of gout — but from damage to the ligaments. That’s the new and surprising information gleaned from this study.

What does this really mean? In the clinic, when a physician sees a patient with known gout now presenting with wrist pain, a diagnosis of ligament instability (not just erosion of the joint) should be considered. The cause is crystalline deposition associated with the underlying condition of gout.

One other finding from this study that was new involved the laboratory preparation of the tissue samples. Tissue removed from the joint at the time of the arthroscopic exam were put either in sterile saline, alcohol, or formalin (liquid formaldehyde, a preservative).

The samples transported to the lab in formalin showed no crystal deposits under the microscope — despite the fact that the surgeons clearly saw them during arthroscopic exam. They concluded that formalin destroys these deposits, whereas saline and alcohol preserve them. The authors suggest transporting future specimens in alcohol to prevent loss of the crystals needed for confirmation of the diagnosis.

Wrist pain can be very disabling for the athlete. This is especially true for gymnasts; tennis, soccer, or volleyball players; and even competitive divers. Pain can occur along either side of the wrist, but when it affects the ulnar wrist (side away from the other hand), surgeons must rule out triangular fibrocartilage (TFC) tears.

The triangular fibrocartilage (TFC) is a thin, oval plate of fibrous cartilage. It is sometimes referred to as the articular disc or radioulnar disc because of its location between the distal radius and ulna (bones of the forearm). Distal refers to the bottom ends of these two bones where they meet the wrist.

This triangular-shaped soft tissue structure binds the distal radius and ulna together while also providing a buffer between the ends of these bones and the wrist bones. The articular disc also creates an even spread of forces between the connecting surfaces of bones.

Besides increasing the stability of the joint, the TFC also helps move synovial fluid to areas of the articular cartilage that have the most friction. Several wrist ligaments interconnect with the TFC to form a stable, but pliable, wrist.

If it turns out that a TFC injury is causing the athlete’s painful symptoms, then the next step is to determine a plan of care that will get the athlete back into competition as soon as possible. The first approach is a combination of antiinflammatories and immobilization in a cast or splint. Physical therapy is often helpful. Steroid injections may be tried if these other methods don’t work.

But if conservative (nonoperative) care fails to change symptoms or improve function, then surgery may be needed. There are two main types of surgical procedures. The first is débridement. The surgeon cleans up any frayed edges and removes any fragments in the area. If this is not enough to improve symptoms and function and the wrist is unstable, then repair of the TFC is done. Most patients requiring a TFC repair need debridement first, then the repair can be done.

In this study, the goal was to see how well athletes with traumatic TFC injury that failed conservative care did after surgery. How soon did they get back to play (return-to-sports)? Could they return at their previous (high-level or full) participation? The hope was to perform arthroscopic debridement or repair and get them back to full function as quickly as possible.

The athletes were all ages from 16 to 42. There were an equal number of right versus left TFCs involved. Athletes involved in all kinds of different sports (e.g., soccer, gymnastics, football, basketball, baseball, golf) were included.

The authors described two surgical techniques for TFC repair: the ulnar-sided repair and the radial-sided repair. Just like it sounds, these two techniques are based on which side of the TFC is torn. Type and location of the incision and drill holes, size of needle to use, and description of the sutures are provided. Drawings are included to show the inside-out arthroscopic TFC repair. The surgeons suggest ways to avoid injuring the nerves when moving the needle in and out of the wrist.

Two-thirds of the group needed a repair done; one-third of the group just had a débridement. Three-fourths of the athletes had an ulnar-sided TFC tear. The remaining patients either had a radial-sided TFC or combination of both radial and ulnar-sided tears.

Results were very positive with most of the athletes returning to their sport within three months’ time. Pain was reduced. Full wrist motion and improved function were achieved. They were able to fully participate at a high-level. Ulnar-sided repairs had slightly better results. The authors suggest this may be because there is more blood supply on that side.

There aren’t very many studies of high-level athletes with this type of injury and treatment. Most athletes at this level are able to rehab without surgery. For those who have surgery, guidelines for post-operative recovery and return-to-play are few and far between. Most of the rehab protocols are based on surgeon preference, not necessarily evidence. A conservative approach suits the surgeon but may not sit well with the athlete who is eager to get back into action.

Until a more aggressive timeline can be studied, surgeons try to err on the conservative side of things. This means giving patients plenty of time to heal in order to avoid problems and complications. The results of this study at least show that arthroscopic treatment of TFC tears (either débridement or repair) is successful for competitive athletes. More studies are needed to compare aggressive versus conservative rehab programs.

Kienbock’s disease is a disorder that affects your bone. For unknown reasons, the blood supply to the lunate, a bone in the wrist is deprived of blood. Without the blood providing nutrients to the bone cells, the bone tissue begins to die. The symptoms include pain in the wrist and loss of motion, so often patients think they’ve sprained their wrist but they can’t remember hurting it.

The author of this article reviewed the current concepts and thinking about Kienbock’s disease.

When trying to determine the cause of Kienbock’s, researchers have several theories, such as repetitive trauma to the wrist, the placement of the wrist bones, and even the size of the lunate. Certain illnesses, such as sickle cell disease, cerebral palsy, and septic emboli may increase the risk, as may the use of corticosteroids, but this hasn’t been proven.

When diagnosing Kienbock’s, doctors will look for certain issues, such as pain and weakness in the wrist but no recollection of trauma to the wrist or hand. The pain may be mild or it may be severe, it may be slowly progressing or it may be sudden. The pain is most often worse at the end of range of motion, especially as the wrist is being extended. Grip strength is also usually less than with the other, non-affected, hand.

X-rays of the wrist may or may not show something – it depends on how far the disease has progressed. There may be signs of collapse in the bone surface or a fracture of the lunate. Some physicians may order magnetic resonance imaging (MRIs) to have a better view of the wrist, especially if the x-rays aren’t showing anything unusual. The MRI can show if there is a loss of bone marrow fat and how dense the bone is.

Once Kienbock’s has been diagnosed, it must be staged. In other words, how bad is it?
Stage 1: Normal x-ray, intensity changes found on MRI
Stage 2: Sclerosing (thickening) of the lunate seen by x-ray, fracture lines may be seen
Stage 3: Lunate surface collapse
Stage 4: Lunate collapse and arthritis is present

Treatment for Kienbock’s is aimed at symptoms because there’s no cure for the disease itself. The goal of treatment would be to help limit the damage, improve usefulness of the wrist and limit pain. Treatment can be with surgery or without. Conservative, or nonsurgical, treatment means using a cast (for about three months). This is generally the treatment for Stage 1 of the disease. Unfortunately, studies show that most patients move on to stage 2 though.

Stages 2 and beyond usually require surgery. In stage 2, the surgeon will cut out the part of the bone that has died, thereby shortening the bone. Revascularization, or re-establishing the blood supply, has been tried with a few different procedures. These involve trying to adjust the load on the bones so there isn’t as much of stress on the bone or by redirecting blood supply. Other surgeries involve bone grafting, fusion or even surgery to affect the nerve. Bone grafts have seemed promising. In one study of 18 patients, 16 had successful grafts at five- and 10-year follow-ups.

Radial shortening, shortening of the bone is considered a simple surgery with good results, but at what stage it should be done isn’t always agreed upon. Joint leveling is another technique, but this isn’t always successful and there are reports that arthritis may be a complication from the surgery. A newer procedure for earlier stages is called core decompression, and this has had fairly good results so far.

In the last stage, stage 4, the surgeon may have to do a denervation, which means cutting the nerve so it no longer causes pain. This can be done alone or in combination with other procedures. While denervation does help some patients, it doesn’t help all, unfortunately.

The author concludes that treating Kienbock’s is still difficult since there are not obvious causes. Advancements in surgical procedures have been helpful in helping to relieve the symptoms and effects of the disorder and seem to have satisfactory outcomes for most patients.

Stenosing tenosynovitis, or narrowing and inflammation of first extensor compartment of the wrist is called de Quervain’s disease. This happens when the sheath of the tendons on the thumb side of your wrist are inflamed or swollen. The disorder affects more men than women, particularly in women who are pregnant or breast feeding. No-one knows what causes de Quervain’s. The authors of this article reviewed the epidemiology to see who is more likely to develop the syndrome.

Researchers went through the Defense medical Epidemiology Database, which collects and stores information on military personnel throughout the country. The researchers broke down the categories to race, gender, military service, rank, and age. They found 11,332 causes of de Quervain’s in the records. Interestingly, the sex of the person was significant – In under 20s, women did have a higher rate of the disorder than men, at a rage of 2.8 cases per 1000 person years while men only had a rate of 0.6. The next highest at-risk age was the 40 years and older group. They had a rate of 2.0 per 1000 person years compared with the under 20s who had a rate of 0.6.

Race played a role as well. Being non-white was a higher risk factor than being white. Blacks had a rate of 1.31 per 1000 person years, others at 1.03, and whites had a rate of 0.82.

The authors wrote that the disorder seems to be the same world-wide. In France, the ration was three women to every man who had de Quervain’s.

There were some limitations to the study, the authors noted. Using military personnel for a health study is limiting due to their unique, usually healthy, situation, as well as sex differences, age, and activity levels. That being said, the records made for an excellent study group.

The carpal boss is a bony part that sticks out of the back of the hand, called the dorsum, at the second and/or third finger joint. Researchers aren’t sure what causes it, whether it’s caused by trauma or that it’s degeneration of bone. They also don’t know how common it is. Osseous coalition is the joining of bone. The authors of this article examined the presence of the carpal boss on 202 wrists of cadavers (bodies) to see if they could determine the incidence and the presence of osseous coalition, and how often it appears.

The researchers dissected 87 pairs of wrists. They examined the anatomy of the wrists when they were in the neutral or bent position and then again extended. They were looking for a visible and palpable (one that could be felt) prominence on the back of the hand.

Thirty nine wrists out of the 202 had the bony prominence and all wrists with the bony prominence also had at least a partial osseous coalition. Ten pairs of wrists had it in both wrists. the osseous coalition was found between at the base of the third finger, the second finger, or between the second and third fingers. None was noted in the other joint areas.

The authors wrote that their study confirmed the high percentage of partial osseous coalition with carpal boss, but they still don’t understand what causes it.

Imagine you have a severely painful wrist from arthritis that limits your everyday life.

Would you trade a few extra years of living in order to live your remaining years pain free? If you said, yes, how many years would equal the value of living pain free?

These are the questions given to hand surgeons comparing the results of one procedure over another.

Surgical treatment for severe and painful wrist arthritis includes arthrodesis (wrist fusion) and arthroplasty (wrist replacement). Without clear and direct evidence of the benefit of one procedure versus another, as patients, we rely on surgeon’s opinions and judgments to guide us.

The literature shows that from the limited studies done so far, surgeons believe the value added from wrist arthroplasty (replacement) is not worth it. The potential complications and risks that come with that procedure outweigh the benefit to the patient. The consensus is that you might as well have a wrist arthrodesis (fusion). You’ll get the same (or better) pain relief, still get the same overall function, and with fewer problems.

In this study, the authors surveyed 73 experienced hand surgeons who had been in practice for 11 to 20 or more years. The survey was a utility survey. This means it was designed to measure the value placed on living with a painful, poorly functioning arthritic wrist compared to living a shorter, but pain free, life.

They calculated the expected quality adjusted life years (QALY) for three patient cases: 1) living with a painful wrist, 2) wrist arthrodesis (fusion), and 3) wrist arthroplasty (replacement). Utility values for each one were compared. The tool they used was designed to place a value on gains in quality and quantity of life from treatment.

The benefit of this type of measurement is that it allows researchers to compare how a surgeon values one surgical procedure over another. Then the cost of each gain in quality adjusted life years (QALY) can be calculated. This helps put the value into economic terms when making decisions about health care policies and spending. In other words, how much value is gained for procedure A versus procedure B? And how much does it cost?

What they found was that from a surgeon’s point-of-view, it would be worth it to trade 14 years of life to avoid having a painful, arthritic wrist. This result suggests that surgeons believe that a painful, functionally limited wrist would severely alter and limit life. As has been reported in other studies, the surgeons in this study also agreed that the value of arthroplasty over arthrodesis is very small.

The authors questioned whether this preference for fusion over replacement may be based on a lack of experience with the benefits of arthroplasty. Most of the surgeons surveyed did not do wrist replacements. It is true that of the studies done so far, the rates of re-operation and revision are higher with wrist replacement. They suggested that maybe if as much time and money is spent improving the wrist implant as has been invested in hip and knee implants, the results would improve dramatically.

In a study of this type, it’s important to know that patients may not judge things the same way surgeons would. The loss of the use of a hand would be quite devastating for a surgeon.

Most patients adjust their thinking and expectations, along with their activities to fit their physical abilities. It may be that it’s one thing to imagine poor health, it’s another to experience it. And the human ability to adapt and cope results in higher quality of life than might be predicted or expected.

Until more and larger studies on wrist arthroplasty are available, patients must rely on surgeons’ opinions and preferences. Given this information, patients may want to review their own goals, needs, and values. It may turn out that patients will adopt a different attitude and approach. Their choices may differ from surgeons’ choices.

Data from decision analysis like in this study provides helpful information. The cost effectiveness of one treatment approach can be compared to another. For many patients, choosing the best treatment may come down to dollars and cents over quality and quantity of life.

Using quality adjusted life years, researchers may be able to help patients calculate their own utility values. Taking into account quality and quantity of life with and without a painful wrist may help with the decision-making process. The same approach could be used with other health care decisions (not just arthritis). More study is needed to evaluate this model with other common conditions for which there is more than one possible treatment choice.

An occasional stiff wrist may not be too bothersome, but if it results in a loss of motion and decreased function, treatment is usually needed. There are several causes of wrist stiffness, including scarring in the soft tissues of the wrist or inflammation in the joint that could be caused by injury, trauma, paralysis, or even surgery.

While the usual treatment for wrist stiffness is physical therapy or surgery, researchers are looking for an alternative, less costly and less invasive (than surgery) treatment. Some doctors have used splints for treatment, but there have not been many studies that look at the splints’ effectiveness and what type of splint would be best. For example, one type of splint uses springs or elastic bands to apply pressure, stretching the joint. But, there are several disadvantages to this type of treatment, ranging from pain to the risk of damaging the joint.

Another treatment is called stress relaxation, which – when researchers examined how it worked – is a stretching technique that looks like it breaks some of the tissue that is causing the wrist to contract, or become tighter and stiffer. In addition to the stretching, therapy can include static progressive stretching. Using a specially designed orthoses, or splint, the wrist is pulled to a straighter position. This technique has been studied for use knees, ankles, and elbows, but not in wrists.

The authors of this study assessed the use of static progressive stretching for patients who had wrist flexion, wrists that were bent inwards and unable to straighten, or extension, wrists that were stretched out and cannot be bent forward. Researchers followed 47 patients who were treated using the orthoses for static progressive stretching. All had tried other treatments without success. The average age of the patients was 49 years (ranging from 18 to 78 years). Some patients had stiff wrists from traumas while others developed following surgeries.

The patients first tried physical therapy for around 12 weeks on average, which involved conventional stretching, range of motion, ultrasounds, using ice (cryotherapy, and transcutaneous electrical nerve stimulation (TENS), which involves sending small shocks to stimulate the injured area.

All of the patients, upon entering the study, were given a wrist device made of a padded forearm cuff and padded hand plate, both attached to a metal base. An adjustable knob on the base would alter the angle of the wrist. The patients were told to adjust the angle of the orthoses until they felt their wrist pull, but without pain. This position was to be held for five minutes. They would then decide if they could tolerate another adjustment for a pain-free stretch for another five minutes. This program continued for 30 minutes at a time. The angle was then changed for the opposite direction and the process was repeated, for total session of 60 minutes. The sessions were to be done once a day at the beginning and then gradually increased up to a maximum of three times per day. The treatment was stopped when there was no change in angle after seven days of treatment in a row or when the physical therapist felt there would be no further improvement.

During and after the treatment, the patients were assessed for any injuries or problems that may have been caused by the treatment. The wrist’s range of motion was also measured with each visit. The results showed that all patients experienced an increase in their arc of motion and their ability to move their wrists after follow up of between six and 24 months, depending on the patient. The arc of motion increased between 5 degrees to 100 degrees and the angles for bending or extending the wrist increased by between 3 degrees and 50 degrees.

There did not seem to be any connection between the age or sex of the patients and if they had good treatment results. When asked how satisfied with the treatment they were, the patients rated an average of 8.2 out of 10, with 10 being the best possible answer.

The authors concluded that the splinting device with static progressive stretch is a useful treatment for patients with wrist stiffness who have not been successful with physical therapy.

Results of studies around surgical outcomes for Kienböck’s disease are not consistent. What works best? When should the affected wrist bone (the lunate) be surgically removed? Can surgeons use the amount of damage to the joint surfaces as a guide in making this decision?

Kienbock’s disease is a condition in which the lunate 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.

The current study reports on the long-term results of proximal row carpectomy (PRC) for advanced Kienböck’s disease. By looking back at results, we may be able to identify when surgery is needed and for which patients.

The wrist is made of eight separate small bones, called the carpal bones. The lunate is one of these bones. There are two rows of carpal bones that connect the two bones of the forearm, the radius and the ulna, to the bones of the hand. Proximal row carpectomy refers to the surgical removal of wrist bones in the row closest to the forearm.

In late-stages of Kienbock’s disease, surgeons focus on treating the wrist osteoarthritis that results when the lunate collapses and dies. One surgical option at this stage is proximal-row carpectomy. Carpectomy means excision (removal) of one or more of the carpal bones.

When the lunate has collapsed, but the wrist joint is not terribly arthritic, the four carpal bones of the proximal row may simply be removed. This allows the distal row (the other four bones) to slide down a bit and begin moving against the forearm bones instead. Without the proximal row of bones, the wrist loses its ability to perform complex movements. It becomes more of a hinge joint like the knee.

The advantage is that there is still a good deal of wrist motion. That’s better than having a wrist fusion, which is another surgical option. Proximal row carpectomy is not the first line of treatment for this condition. It’s really considered a salvage procedure. That means it’s a way to save motion at the wrist. A proximal row carpectomy is a good solution when the patient needs a flexible wrist more than a strong one. It is used when there is advanced disease to try and avoid fusing the wrist and losing all motion.

There are some potential disadvantages to proximal row carpectomy. After the carpectomy, the main load on the wrist with grip and functional activities goes through the new capitate-radius joint. This is where the capitate bone of the wrist now joins the radial bone of the forearm.

In this study, 21 patients with stage III or IV (advanced) Kienböck’s disease were followed for an average of 10 years. The range was from four to 17 years. They all had a proximal row carpectomy for advanced Kienböck’s disease. The condition was diagnosed by clinical exam and X-rays.

Outcomes were measured by pain, motion, grip strength, and function. Disability was assessed using two tools: the Quick Disabilities of the Arm, Shoulder, and Hand (Q-DASH) and the Patient-Related Wrist Evaluation (PRWE). These self-reported surveys are both reliable and valid to measure results mentioned. Patient satisfaction was also measured on a scale from extremely satisfied to extremely dissatisfied.

X-rays were taken right after the carpectomy and at the final follow-up appointment. The main area of interest was the joint space between the capitate and the radius. Narrowing of the joint space is a possible negative outcome of the surgery.

Most of the patients (89 per cent) were either satisfied or extremely satisfied with the results. No one was dissatisfied. But half the group reported mild pain that could account for less than 100 per cent satisfaction.

Although the patients weren’t having any symptoms of it, degeneration of the radiocapitate joint was seen on X-rays in almost everyone. Joint narrowing ranged in degree from mild to severe. Most of the patients were able to return to their jobs without any problems. Only one manual laborer was unable to go back to his previous occupation.

Failure was defined as persistent pain requiring a wrist fusion. All failures occurred in patients for different reasons. In one case, cysts formed in the capitate and the patient had a full thickness defect in the joint cartilage. In another case, the bones of the wrist were jammed together causing weakness and instability.

This may be the longest study done looking at the long-term results of proximal row carpectomy for advanced Kienböck’s disease. The authors admit they still were unable to say when a carpectomy should be done. Using joint cartilage between the capitate and radius as a basis for decision didn’t pan out. And some of their results conflicted with the results of other studies suggesting the need for continued investigation of this problem.

Triangular fibrocartilage complex is a disorder of the wrist. The cartilage, tough fibrous connective tissue, is damaged or torn. The most common sign of triangular fibrocartilage complex is pain on the ulnar side of the wrist, the outside of the arm, closest to the “little” finger.

There are two classifications of triangular fibrocartilage complex called the Palmer classifications, each of which has several sub-classifications, depending on the extent of the damage: Class 1 means that the injury happened as the result a trauma and class 2 is the result of degeneration. Class 2 injuries are more common than class 1. It was also thought that Class 1 injuries were more difficult to treat than were class 2 injuries.

Researchers were interested in learning about the cells were made up, how deterioration happened around the injured area and how this affected healing. There was a common thought that patients who had Palmer class 1A injuries, where the cartilage is perforated, or a hole has been made, in the middle, could not have their lesion repaired. However, the researchers found that they can heal. In one study, patients with class 1A injuries had arthroscopic surgery, done with tiny incisions and long instruments with a camera on one end. The arthroscopic surgery allowed the doctor to see the injury and shorten the bone, repairing the damage. When the patients were examined by arthroscopy later, half of the tears or perforations were healing. In a different study, surgeons removed tissue around the tears from people with class 1A injuries and examined them for degeneration of the tissue cells. They found that even 18 months after the injury, there was degeneration in the cells and that they were beginning to look like a classification of degeneration, the Palmer 2C class, where the injury had perforated but due to degeneration instead of trauma.

The authors of this article wrote that the recent advancements of high-resolution, more detailed MRIs (magnetic resonance imaging) and arthrography (joint x-rays) have allowed doctors to study these injuries in much more detail. When these tests became available, researchers began comparing their findings with the tests against those from arthroscopic examination. They found that while the tests were accurate for some types of injuries, they weren’t for others.

As researchers worked at trying to find better ways to perform the surgery on the wrist, they noticed that the triangular fibrocartilage complex was very much like injuries in the knee. So, by using the techniques used in arthroscopic knee surgery, the researchers were able to develop more precise and effective techniques for the wrist. By using an all-inside arthroscopic technique, the surgeons were able to see what the problem was, diagnose it and treat it.

Avascular necrosis or osteonecrosis (bone death) of the carpal bones (wrist) causes pain, limited motion of the wrist, and weakness. Frequently, patients with this problem end up with arthritis in the affected wrist. The author of this article examined different treatment methods of avascular necrosis.

The most common type of avascular necrosis is called Kienbock disease, a disorder where the blood supply fails to reach a small bone, called the lunate in the wrist, causing bone cell death. Patients often report that it feels at first like a sprained wrist. There are various types of treatment for Keinbock disease and there isn’t big agreement as to which is best. The treatments include leveling off the joint, removing part of the bone (osteotomy), bone grafts, or fusing the bones (arthrodesis), among others.

One of the procedures, joint leveling involves lengthening of the ulnar bone (one of the forearm bones) and shortening the radial bone (the other forearm bone). It has been found to be effective in helping the wrist. Patients who have this type of surgery have reported less pain, and better strength and range of motion of the wrist. But, there have also been many reports of non-union, where the bones don’t join and heal together.

Surgeons also partially fuse the wrists of some patients with Kienbock disease. Although this procedure can reduce pain and prevent further damage, it also reduces the range of motion of the wrist, which can be difficult for some patients. Bone grafting is also done with some success, resulting in less pain and increased strength. Some patients did develop signs of arthritis later on, however.

Another form of avascular necrosis is osteonecrosis of the scaphoid or Preiser disease. In this disease, the osteonecrosis happens in the scaphoid bone in the wrist, the first bone nearest the thumb. It is a rare disease so there aren’t any tried and true treatments. Treatments can include debriding the damaged and dead tissue from the area, grafting, or removing part of the bone.

Avascular necrosis of proximal scaphoid associated with fracture and non-union is another problem that doctors encounter. The scaphoid bone is easily broken so it’s a common injury. Sometimes, when the bone is broken, the blood supply is cut off and this can cause cell death, or osteonecrosis. As well, the bone doesn’t always heal. Non-union occurs in between 5 percent to 15 percent of wrist fractures. To treat this problem, surgeons often choose bone grafting but this may also result in non-union.

The author wrote that this condition can be difficult to treat with surgery and although the different procedures are available, further study is needed to find the best types of treatment for the each form of osteonecrosis.

Dorsal wrist impingement is an injury where the back of the radius (one of the forearm bones) hits against the wrist bones and traps the nerves. It’s a common injury, particularly in sports like gymnastics, where the gymnasts place a lot of force on their wrists with hand springs and walk overs. However, it can also occur from a minor injury.

When a patient has a dorsal wrist impingement, there is usually pain on the top of the wrist, especially when the hand is bent back towards the shoulder, as when pushing a door open. Usually, the first treatment for the problem is injections of a corticosteroid to the painful area and rest. Unfortunately, not all cases respond to this and then surgery may be necessary.

There is no specific test to diagnose dorsal wrist impingement. It’s not seen on x-ray or imaging, for example. So doctors have to rely on the patient’s history of the injury and by ruling out other problems that may be causing the wrist pain. Dorsal wrist impingement has specific location of pain and this pain can be brought on by certain wrist movements. Also, if it truly is dorsal wrist impingement, corticosteroid injections should have helped relieve the pain somewhat – perhaps relieving up to 70 percent of the pain, for several weeks. So, in order to decide on surgery, the patient should have been treated with at least one or two corticosteroid injections and have rested the wrist for at least three months.

Patients who should not have this surgery are those for whom dorsal wrist impingement can’t be absolutely diagnosed, as well as those who are in poor health, if a patient isn’t compliant with treatments, or has an infection.

Following surgery, the wrist isn’t braced or casted. In fact, wrist movement is encouraged and the goal is to have full range of motion of the wrist within two to three weeks of surgery. Strength rehabilitation begins once range of motion is full and patients generally are able to return to office-type work within two weeks of surgery and to heavier work within six weeks.

There are some complications related to the procedure that should be taken into consideration and these complications are related to wrist surgery in general, not specific to surgery for dorsal wrist impingement. While performing the surgery, the nerves to the wrist are vulnerable to being damaged, for example. And, after surgery, if the patient isn’t compliant and doesn’t participate in exercises to regain range of motion, they may lose the ability to bend the wrist, although the risk isn’t as high with arthroscopic surgery as it is with open surgery.

Rheumatoid arthritis is one of the many diseases that fall under the umbrella of arthritis. It is one of the most outwardly obvious arthritis types because of the way it can deform the joints, often the fingers and wrists. Rheumatoid arthritis is an inflammatory disease in which the joints become inflamed and swollen, and quite painful. Eventually, as the inflammation gets worse and the shape of the joint is changed, patients can find it more and more difficult to use the joint.

Although rheumatoid arthritis is associated with aging, anyone can get it at any age. The author of this article discussed the case of a 38-year-old woman who had had rheumatoid arthritis for 10 years. Her treatments over the years included strong medications called methotrexate and others in the anti-TNF agent groups. She has had both knees replaced. At this point, the patient was not having any signs of arthritis in the shoulders or elbows, but her wrists were affected severely. On a scale of zero to 10, with zero being no pain and no difficulty moving or using the wrist and 10 being the worst possible pain and inability to use the wrist, the patient scored her right wrist (her dominant hand) as a nine and the left as a six.

The question the author posed about this case was what type of surgery would be best for this patient. According to current opinion, the best procedure would be an arthrodesis, or the fusing of bones in the wrist. This would allow for realigning the wrists and making them more stable. At the same time, the surgery would fix the breakdown of the joints.

Total wrist arthrodesis is a common surgery and doctors feel that it is a reliable form of treatment if the wrist is severely destroyed from rheumatoid arthritis. One disadvantage to the surgery is by fusing the bones, the wrist becomes less flexible, but the benefit of pain relief and stability proves to be more desirable. In cases such as with this patient, who needs both wrists corrected (bilateral) as opposed to just one (unilateral), there is discussion about the best way to fuse the bones together. One recently published article says that with bilateral repair, one wrist should be fused slightly bent in towards the body and the other slightly outward, toward the shoulder.

Bilateral repair itself brings about discussion: should it be done at all? The general feeling is that while it is beneficial for the patient to undergo general anesthetic only once and have bilateral repair, being unable to use both hands poses problems attending to activities of daily living, such as personal hygiene.

Another option for surgery is the wrist replacement, or arthroplasty. In the past, many wrist replacements have failed. Either the wrists aren’t balanced properly, they become dislocated, or the implant fails, but these are with the older types of implants. The newer implants have a higher success rate. Advantages of the replacement include studies that show patients who had the replacement were more able to perform personal hygiene tasks than patients who had the arthodesis and they had range of motion that wasn’t available after arthrodesis. There have been patients who had both wrists done, but one with the arthrodesis and one with the replacement. In following up with the patients, researchers found that the patients were most satisfied with the wrist with the replacement. That being said, the disadvantage of the replacement is the risk of the implant breaking or failing.

The author wrote that there is not enough evidence to support either surgery being better than the others. The studies that have been done are small and subjective. Currently, the gold standard, or the treatment most widely used and supported, for rheumatoid arthritis of the wrist is arthrodesis. However, as the replacements become more advanced and new designs are developed, replacements may become more common because of their advantages when they function correctly.

Kienbock disease, a disorder where the blood supply fails to reach the small bones in the wrist, causing bone cell death, often feels at first like a sprained wrist. Unfortunately, unlike a sprained wrist, Kienbock disease needs treatment to remove the damaged part of the bone. To do this, surgeons have been performing a procedure called radial osteotomy, where they remove part of the bone.

Three studies have been done looking into the effectiveness of the surgery, but none of the studies looked at the results from the patients’ point of view. The studies did conclude that the wrist function was improved following an osteotomy, but the authors of this study wanted to assess how patients evaluated the surgery and its outcome.

The researchers found 19 patients with Kienbock disease who underwent radial osteotomy. The patients who had their surgery before 1981 saw their radius shortened by about four to five millimeters, while those who had their surgery after 1981 only had about two to three millimeters removed.

The patients were sent letters from the researchers that contained the Disability of the Arm, Shoulder and Hand (DASH) questionnaire and questions regrading their satisfaction with the surgery, as well as their current status with the wrist. The DASH questionnaire looks at the ability to perform certain activities with the affected hand and symptoms, scored on a scale from one to five. One meant that the patient had no difficulty performing the activity, while five meant that the patient was unable. The other questions were based on three grades: improved, unchanged, and worse. Pain was assessed with four grades: no pain, occasional mild pain, tolerable moderate pain, and severe to intolerable pain.

Thirteen patients responded to the letter and 12 were examined for wrist range of motion (how many degrees the wrist can move around compared to the normally accepted movement), grip strength in the affected hand, and the wrist score. The patients were rated on a scale of one to 100; 80 to 100: excellent outcome, 65 to 80: good outcome; 50 to 65: moderate outcome; and less than 50 was considered poor outcome. X-rays were also done to assess the bone structure.

The researchers found that 12 of the 13 patients reported after the surgery they had an improvement in pain, 10 reported better range of motion, and 11 better strength. At the current evaluation, seven patients said they had no pain and six had mild pain. Ten patients returned to their previous jobs. None of the patients reported any worsening of pain, range of motion, or strength.

Before surgery, the average range of motion ranged from 20 degrees to 68 degrees, with a mean number of 40, for bending (flexing) the wrist and 30 degrees to 62 degrees, with a mean number of 46, for straightening out the wrist. After the surgery, the mean bending was 58 and the mean extension was 54. Mean grip strength went from 18 kilograms before the surgery to 28 after.

There were some limitations to the study, the authors wrote. These limitations included the fact that this was a retrospective (looking back) study, only 13 patients responded, the small number of patients made it difficult for statistics, and the surgeries were not the same for all patients. However, despite these issues, the authors state that the results of their study backed up the findings of the previous studies, which found that radial shortening osteotomy can provide “reliable, long-term results.”

In this article, physicians from the University of Medicine and Dentistry of New Jersey (UMDNJ) bring us up to date on perilunate discloations. A perilunate dislocation is a wrist injury that occurs when there is enough force through the wrist to tear the ligaments and displace the lunate. The lunate is one of several wrist bones.

The injury really involves a series of damaging steps. First, the supporting ligaments are torn. As the load increases, a bone fracture can occur. The scaphoid bone next to the lunate takes the brunt of the force and fractures. With enough force, the lunate is then forced into the carpal canal.

The most common mechanism of injury is a fall onto the extended or outstretched hand. The palm is flat, the wrist is bent, and the full impact is on the wrist. When there’s enough force to cause bone fracture and dislocation, there can also be injury to the nerves and blood vessels in the area.

The diagnosis is missed in one-fourth of all cases. Early recognition of the problem is needed to avoid long-term problems and complications. There are two important diagnostic clues. The first is the rapid development of carpal tunnel syndrome (CTS).

With the lunate bone in the carpal canal, pressure is placed on the median nerve causing CTS. An obvious deformity (change in the wrist and hand appearance) may be present. There may also be a loss of blood flow to the median nerve below the level of the injury. If this happens, the hand and fingers may become cold and pale or blue/purple in color.

Symptoms of CTS include pain, numbness, and tingling of the wrist, thumb, index finger, and half of the middle finger (the side closest to the index finger). This is the part of the wrist and hand that the median nerve supplies with sensation.

The second diagnostic clue comes from X-rays taken of the wrist. To avoid missing the correct diagnosis, X-rays should be taken for all hand injuries. This recommendation comes from the American Society for Surgery of the Hand.

The authors also point out the importance of taking more than one radiographic view. A posteroanterior (back-to-front) view will not show a lunate dislocation. It is necessary to take a lateral (from the side) view. The lateral radiograph will clearly show the extent of the injury.

The physician will check the pulses to look for any vascular (blood vessel) damage. With a bone fracture and/or dislocation, there is usually loss of normal motion. Pain and swelling limit motion. With ligament damage, dislocation, and/or fracture, the wrist is unstable. Surgery is needed to repair and reconstruct the wrist.

The surgeon tries to restore full motion and function of the wrist and hand. A thorough examination and diagnosis is needed to know the full extent and possible effect of all the injuries. It will be necessary to realign the two rows of wrist bones with the radius and ulna (forearm bones) on one side of the wrist and the fingers on the other side.

Treatment depends on the amount and type of damage present. A simple dislocation without fracture and no signs of CTS can be reduced (bones put back in place). The procedure is done without an open incision. This procedure is called a closed reduction. The wrist and hand are immobilized in a splint or cast.

After the swelling goes down, the surgeon will re-evaluate the wrist to determine the need for operative treatment of the torn ligaments. Suture anchors are used to reattach the ligaments to the bone. Any fractures are treated at the same time. Pins or screws may be needed to fix or hold the bone in place. A long-arm cast from above the elbow down to the thumb and hand may be needed.

Anyone with rapid onset of carpal tunnel syndrome will need decompression of the median nerve. This requires the dislocation to be reduced and held in place with a wire until healing takes place. Sutures are used to repair the torn volar ligament across the carpal tunnel.

The prognosis is good for perilunate dislocation with early detection. Reduction and/or surgical treatment of the dislocation and any other bone or soft tissue injuries improve outcomes and limits disability. Recovery of full strength and motion can take six months to a year. Missed injuries with a delayed diagnosis do not respond as well.

The triangular fibrocartilage is found on the wrist across the two bones in the forearm. The cartilage allows the arm to move smoothly. If this cartilage is torn, the injury can have severe effects on the use of the arm and hand. Currently, acute tears, ones that happened suddenly, are treated by bracing or casting the arm, or by surgery. Originally, the surgery was done with a traditional open incision, however, as arthroscopic surgery (a technique that uses tiny incisions to allow long, thin instruments and camera inside to do the repair) improved, it was used more often to repair this type of injury.

The results of arthroscopic surgery were mixed. While the surgery is less invasive than traditional surgery, the physicians felt that it was not as effective. The authors of this study wanted to compare the effectiveness of the open versus arthroscopic surgeries as there was no record of such a comparison having been done.

Seventy-five patients were studied: 36 had arthroscopic surgery and 39 had an open repair surgery. The hands were assessed by physical examination findings, which included the presence of wrist pain, grip strength, range of motion, and the whether the wrist joint was stable. Before surgery and at follow-up of between 33 to 55 months after surgery, the patients were re-examined and asked to complete some questionnaires: the Disabilities of the Arm, Shoulder, and Hand Score (DASH) – which measures on a score of 0 to 100 the patient’s own assessment of how the injury has impacted his or her life, the Patient Reported Wrist Evaluation (PRWE) – which is composed of two sections that evaluate pain and function from the patient’s perspective, from 0 to 150 with 0 being normal, and the Visual Analog Scale (VAS) – which is for rating pain on a scale of 0 to 10, with 0 being no pain. The researchers used a scale called the Mayo Modified Wrist Score (MMWS), which measures on a scale of one to 100, with 100 being normal wrist function.

Before surgery, the MMWS was an average of 65.6 in the open surgery group and 63.5 in the arthroscopic group. Joint instability was present in 27 of all the patients, with no difference between groups.

After surgery, all patients had their arms splinted to prevent the forearm from rotating and this was for a period of five to six weeks. The average MMS after surgery was 71.2 in the open surgery group and 60.6 in the arthoscopy group. Pain in the open group improved by an average 10.9 points in the open group and 11.1 points in the arthroscopy group. Function improved by an average of 13.1 points in the open group and 12.3 points in the arthroscopy group. When the researchers evaluated grip and function, the differences in improvement between the two groups was not statistically significant.

In the past, reoperations were sometimes necessary for this type of surgery. In this study, 17 percent of the patients needed reoperations because of instability, but there was no difference between whether they were part of the open or arthroscopy group. The researchers did find that more females than males needed repeat surgery.

The authors concluded that there was no big difference between either technique, although there was a bit of a higher rate of pain after surgery in the open group (14 out of 39 patients) compared with the arthroscopy group (eight out of 36 patients).

Usually, treatment of a break in the scaphoid, the largest bone in the hand, that hasn’t moved or displaced is casting. This has an 85 percent to 90 percent success rate for treatment if the casting is done quickly. However, casting takes time and is inconvenient, and recovery of strength and movement following removal of the cast can take some time.

In the mid-1980s, some researchers claimed that the success of casting was only 50 percent so they introduced a new treatment with hardware in order to stabilize the fracture. According to their study, after 12 months, all repaired fractures were still in place. Other studies have found good success with the screw repair, along with rapid return of use of the hand. The drawback, however, is that the procedure is surgery, which involves using the surgical suites, equipment, and manpower. There is also the question as to whether introducing the screw into the joint could contribute to the development of osteoarthritis.

The authors of this study looked at the long-term outcomes of patients who had either been casted or had undergone the screw implantation. Their goal was to see which treatment offered the best outcomes.

Patients were divided into two groups, 42 patients were casted and 43 underwent surgery. The mean age of all the patients was 31 years for the first group, 32 for the second.

Among the patients who were casted, their casts immobilized their hand from below the elbow. It was worn for six weeks and then removed for evaluation. Following evaluation of the bone union, it was reapplied for an extra two to four weeks if the doctor recommended.

The patients in the surgical group wore a splint on the affected hand for about two weeks after the surgery. After two weeks, for most patients, the splint was changed to a cast for an additional three weeks.

Follow-up at 10 years provided answers from 75 of the original 85 patients. The patients underwent x-rays and were assessed for sensitivity of the scar area, tenderness, joint movement, grip strength and pinch strength. Patients filled out questionnaires about their hand, including a disability questionnaire called the Disabilities of the Arm, Shoulder and Hand (DASH) and the Patient-related Wrist Evaluation (PRWE).

The researchers found that most patients in both groups had no symptoms, although two did have high scores in the DASH questionnaire. More patients who had surgery found that their wrist did not function as well as it had before the fracture and surgery, although the researchers said that the difference was not significant.

When assessing range of motion, those who did not have surgery had better range of motion than the other group. Strength, both pinch and grip, did not vary significantly between groups. The researchers looked for signs of osteoarthritis (with the x-rays) and it was found in one patient who did not have surgery and in 11 who did have surgery.

The authors conclude that the surgical procedure as treatment for treatment of scaphoid fractures did increase the risk of developing osteoarthritis, despite the appeal of the high union rate, short cast time, and quick return to work, which they felt was transient. They pointed out that such patients should be chosen with care.