News Category: Wrist

Professional volleyball players are at risk for a problem called de Quervain
disease. This study shows increased training time and repeated trauma to the wrist and base of the thumb cause chronic inflammation of the tendons.

De Quervain disease occurs when the extensor pollicis brevis (EPB) and abductor pollicis longus (APL) tendons of the thumb are involved. This is the first study to look at factors causing de Quervain disease in volleyball players.

Professional and nonprofessional players with de Quervain disease were included. Players were put into two groups based on symptoms and physical findings. Group A had mild symptoms and was treated without surgery. Group B had more severe pain and loss of motion. Group B had surgery to release the tendons. In some cases the nerve was cut to keep it from sending pain signals.

Most of Group B was made up of the professional players with increased training times. During the operation, surgeons found many changes in this group. A fibrous wall separated the two tendons in half the cases. In more than half the patients, the APL tendon had many separate tendon coverings called a tendon sheath.

De Quervain disease has been found in tennis players, video game players, and now, volleyball players. Overuse, repeated movements, and trauma are the most likely risk factors. Professional players are affected more often because of the higher number of training hours.

Does carpal tunnel release (CTR) work for older adults? The answer is a resounding ‘yes’ according to this study in 75 patients aged 65 and older. That’s good news because carpal tunnel syndrome (CTS) seems to be more common and more severe in older adults.

CTS is a nerve condition caused by pressure on the median nerve as it passes through the wrist. The bones and ligaments of the wrist form a natural opening or tunnel. The nerve passes through this tunnel. Anything that reduces the size of the carpal tunnel can put pressure on the nerve and cause painful symptoms. Changes in the nerve itself can also bring on CTS.

All patients included in the study had to be 65 years of age or older in good mental and physical health. Symptoms, motion, and strength were measured before and after surgery. Use of the hand and wrist was also measured at home and at work.

Patients reported numbness and pain was much better. Symptoms went from severe or very severe to mild or none. Grip and pinch strength improved. Overall 83 percent of the patients were happy with the results of the CTR.

It’s true that younger patients have better results after CTR compared to older patients. But this study shows that older patients can get good results after CTR.

Picture this: two groups of workers in an auto assembly plant. All have carpal tunnel syndrome (CTS). One group wore custom-made wrist splints every night for six weeks. Both groups watched a move on CTS and how to prevent it at work. Which group had the best results? That’s the focus of this study from the University of Michigan.

Researchers found the splinting group did much better than the control group. And the improvements were still present a year later. The workers in both groups were evenly matched in terms of age, size, gender, and symptoms. The splinted group did have more job dissatisfaction compared to the control group.

At the end of six weeks both groups had less discomfort in the hand and wrist. The splinting group also reported less discomfort in the elbow and forearm. Almost half the treatment group said they were “much better.” Only one worker was completely better.

A major finding of this study was the effect of splinting on symptoms when nerve function isn’t normal. Symptoms improved even when the function of the median nerve didn’t change. In other words, the splinted group got better even when the nerve was impaired. The control group only got better when nerve function was normal.

The authors conclude that splinting at night for CTS can improve symptoms even without normal nerve function. It also reduces the cost of medical care for this condition. A larger study with more workers is needed before advising the use of splints first before other treatment.

Heat can be an effective treatment for wrist injuries. Low-level continuous heat for up to eight hours was used in this study. All patients had wrist problems such as sprains, strains, or carpal tunnel syndrome. A special heated wrist wrap was worn for three days.

Pain level, joint stiffness, and grip strength were measured before starting treatment. These measures were taken again every hour for the first eight hours, then every two hours after that. Patients were followed for three days of treatment plus two days after treatment.

Results showed that pain relief occurred during the first three days for all wrist patients. Patients with carpal tunnel syndrome had the most relief from joint stiffness. Grip strength increased at the end of the treatment on day three.

The authors conclude that low-level continuous heat wraps can help in the treatment of common wrist problems. It’s likely that the heat increases blood flow to the area. Blood helps remove cells of inflammation in the area of tissue injury. The collagen tissue and muscles then become more flexible.

Stick your thumb out to hitch a ride and you’ll see the extensor pollicis longus (EPL) pop up. This tendon runs along the back of the wrist and thumb. Sometimes this tendon ruptures without warning. It could be job-related, or it can occur after the lower arm is broken. But many times it happens with no known cause.

There are two theories about spontaneous EPL tendon rupture. One is based on poor blood supply to the area (a vascular cause). The other is a mechanical theory. After fracture, the tendon rubs against the bone and tears. It’s possible that both vascular and mechanical problems occur at the same time.

Researchers at the Mayo Clinic measured the gliding resistance of the normal EPL tendon. Then they compared it to another tendon. They used the extensor digitorum communis tendon (EDC) as the model tendon because it’s in the same area of the thumb, has a similar function, and has a much lower risk of rupture.

Frozen human cadavers were used in the study. The hand and lower hand were attached to a device to move the thumb. Researchers put two marks on the tendon and measured how far the marks moved when the thumb was moved. A weight attached to a special ring at the joint and pulled through a pulley system made it possible to measure motion. By changing the position of the pulley, the wrist angle and direction of motion was changed.

The authors found wrists position with the least resistance. One position was with the wrist in neutral. A second was with the wrist angled back and slightly toward the pinky-side of the hand. The authors suggest that gentle, active motion of the thumb in this position will reduce mechanical irritation of the tendon. At the same time, the tendon will get lubricated. Doctors and therapists use this information to know the optimal positions for splinting the wrist when treating the EPL tendon.

There was a time when some doctors said the best treatment for a wrist ganglion was to smack the wrist with a heavy book. A more up-to-date treatment is surgery to remove the fluid-filled cyst. That operation has also progressed from an open procedure to arthroscopy.

In arthroscopy, the doctor inserts a long, slender tool into the area. The scope has a tiny TV camera on the end. It projects the view on a TV screen for the doctor to see what he or she is doing. The entire ganglion, its stalk (when visible), and part of the joint capsule are removed. Doctors are careful to avoid injuring the nearby tendons, ligaments, and nerves.

With any change or new way of doing something, doctors want to know how well it’s working. In this study doctors at the Mayo Clinic report on the results of 41 patients who had a wrist ganglion taken out by arthroscopy. They found that motion and grip strength improved in all patients. One-fourth of the patients had stiffness at first. No one had an unstable wrist after the operation. Pain levels were also reduced. The ganglion came back in two patients and was removed with an open operation.

The authors conclude that arthroscopic removal of wrist ganglions is safe and reliable. The results of this study show that arthroscopy for ganglion removal is just as good as creating a large incision. Arthroscopy actually has some advantages over an open incision. The ganglion can be seen from all sides and taken out without damaging nearby soft tissues. The patient can start to move the wrist and hand early. The result is less stiffness and a faster return to normal.

In this article Dr. Trumble, Chief Hand Surgeon from the University of Washington Medical Center in Seattle, reviews nonhealing fractures of the scaphoid bone. The scaphoid is a small bone in the wrist between the forearm and thumb. It’s broken most often when someone falls with the hand stretched out and the wrist tilted slightly towards the ring finger. When a bone doesn’t heal properly, it’s called a nonunion fracture.

X-rays don’t always show the fracture. Problems can occur if the scaphoid fracture isn’t treated properly right away. Today, MRIs and CT scans help doctors see the fracture early on, so they can plan treatment. Sometimes casting the arm is all that’s needed. Surgery may be required if the bone is broken into pieces or moved out of position.

Dr. Trumble and his associates review the anatomy and blood supply of the scaphoid in detail. They tell other doctors what to look for during the exam and on X-ray and how to avoid a nonunion fracture at this site. A scaphoid fracture can stop the blood flow to the bone. A special graft to replace the bone with bone that has a good blood supply may be needed.

Other surgical options are also discussed. Ways to do each operation are shown with detailed pictures. The wrist is a very complex area, and deformities can occur after injury. Dr. Trumble reviews how to use screws and wires to hold the wrist together. If the wrist fracture still doesn’t heal, the wrist may collapse. The scaphoid may have to be taken out and the wrist fused. This is called a salvage operation.

It’s hard to get a handle on how to treat rare diseases. Kienbock’s disease of the wrist is one of those conditions. The lunate bone in the wrist falls apart because of a lack of blood supply. The cause is unclear. But the results are pain, loss of motion, and reduced function.

By keeping track of patients’ results after various treatment methods, doctors bring new information to the clinic. In this study, doctors in Japan followed 25 patients for up to 15 years after surgery. During surgery the doctors removed a piece of bone from the end of the radial bone in the forearm. This is done when the end of the radius is pressing on the lunate. The operation is called a radial osteotomy.

The authors of this study say shortening the radius is a reasonable treatment method for Kienbock’s disease. Improved motion and function last a long time. X-rays didn’t show much change, but new test measures showed improved blood flow to the lunate. They found a better way to measure these changes using the standard X-rays. They made up a new grading system to rate improvement in the lunate bone. The grading system looked at the height of the bone, bone density, and the space between the bones. The researchers think the radial osteotomy resulted in slow but steady improvement to the inner structure of the lunate.

Overall results showed pain, motion, and grip strength were much better after surgery. The results lasted five, 10, even 15 years for most of the patients. The biggest problem after radial osteotomy for these patients was the onset of osteoarthritis (OA). Even with OA, however, symptoms and use of the wrist and hand remained improved. In other words, patients didn’t seem too bothered by the arthritis.

This is the second report from these doctors in Germany. At first they reported the results of a total wrist replacement after 18 months. They used an uncemented implant made of cobalt and chrome. Joint surfaces of the implant were coated with titanium.

Wrist replacements are fairly new. Although they’ve been used for the past 30 years, the newer and better designs today makes them like a new operation. However, they don’t have the stable results of hip and knee replacements yet.

Forty patients with rheumatoid arthritis were followed. At the time of the wrist replacement, the patients had good function, reduced pain, and were satisfied with the results. Over two years later, doctors reported on the long-term results.

In this latest study all the patients started developing problems after the 18-month mark. The wrist implant started moving and the wrist drifted into a position called ulnar deviation. This means the fingers drift away from the thumb. Wrist range of motion and grip strength was also much decreased.

Many patients had loosening of the implant because of bone softening and breakdown. Some had a complete dislocation of the wrist implant. The replacements had to be removed and the wrist fused for all 40 patients.

When the implants were removed, the doctors found quite a bit of wear on the joint surfaces. There were particles from the implant in and around the tendons and even into the fingers. The debris was stuck to the soft tissues and couldn’t be removed.

The doctors in this study were unsure why the implants failed. Perhaps there was loosening because cement wasn’t used to hold the parts together. Maybe the body reacted to the titanium alloy. Using the same implant a second time wasn’t possible because there was too much bone loss and soft tissue damage. Fusing the wrist was the only option.

The authors were very disappointed with the results of wrist replacements in patients with rheumatoid arthritis. They advised that the use of such implants be abandoned in these cases.

“Be content in the moment.” A wise saying, but this may be hard to do when you have advanced arthritis of the wrist. Middle-aged men in the prime of their lives are affected most often. A previous wrist injury is a common factor.

Joint replacement isn’t always a good option for active adults. Other ways to save wrist motion are presented in this article. Removing one of the two rows of wrist (carpal) bones is one treatment. This is called a carpectomy.

Fusion (called arthrodesis) of the wrist joint is another option. The decision between carpectomy and arthrodesis is made jointly by the doctor and patient. The patient must know the possible complications of each procedure.

The authors of this report describe in detail each method and the uses of each treatment. They outline for the doctor and patient the results reported in other studies for both carpectomy and arthrodesis. They suggest trying other (nonoperative) treatment first. Splints, drugs, or injections are possible choices. The patient can always have surgery later if pain continues.

Setting up a computer workstation properly sometimes seems to take a special degree. There’s an awful lot of twisting, turning, and adjusting. But for people who spend long hours typing, these little adjustments can make a big difference. Even small changes in the way keyboards are set up can give relief to aching fingers, wrists, and forearms. Small changes may also help prevent carpal tunnel syndrome. This condition is a potentially serious wrist and forearm injury that can be caused by overuse.

These researchers are doing studies on the way keyboard use affects the wrist and forearm muscles. Experts recommend that typists position their hands so that the wrist is not bent either up or down. This article reports the results of a study on how keyboard slope affects the way the muscles of the forearm work.

Sixteen typists were fitted with special devices to measure muscle activity. They typed for six minutes on keyboards with different slopes. One keyboard was about at the usual, built-in slope. One keyboard was perfectly flat. But the other keyboards sloped away from the typist–not a common keyboard set-up.

Typing was equally fast and accurate on all the keyboards. The muscle testing showed that forearm muscles worked less hard on the sloped keyboards. The wrist was also bent much less with the sloped keyboards.

However, the typists reported that the most sloped keyboard was not comfortable to use. The sloped keyboards also changed the way the
forearm was positioned. The wrist angle produced by the slope could cancel out the benefits of the sloped arrangement. The authors also note that using wrist rests correctly is important if a sloped keyboard is going to work.

So don’t adjust your keyboard slope just yet. But this research is a good base for finding new ways to help typists prevent overuse injuries.

You’re about to read the checklist for a surgeon doing a proximal row carpectomy (PRC) in the wrist. Anesthesia . . . incision . . . separate tissue . . . move tendons . . . find the wrist joint . . . remove the capsule . . . take out a row of bones. What? Take out a row of wrist bones? You heard correctly. The doctor may decide to remove a row of bones in the wrist when trauma or arthritis is causing constant pain and collapse of the joint.

Doctors in this study followed 20 patients who got PRC for up to 17 years. They hoped to find out what kind of results PRC patients have in the long run. A physical exam, X-rays, and a patient survey were used to measure results. Wrist range of motion, grip strength, and the shape of the bones left in the wrist were used to determine success or failure. Pain and return to work were also measured.

None of the patients felt the wrist was weak. Most returned to work even when their job required manual labor. A small number of patients had pain and needed another operation later. Wrist range of motion was better than half of normal, and grip strength was at least 80 percent of the other side.

The authors conclude PRC is a dependable and durable operation with good results. The remaining joint doesn’t collapse and isn’t destroyed over time. The authors plan to keep following patients with a PRC for as long as possible to see if wrist pain or problems come back in later years.

Doctors and researchers at the University of Iowa compared treatment for patients with severe wrist arthritis. One group had a wrist fusion. The other group got a new wrist joint.

This study measured pain, motion, and function to see which treatment was better. They used complications after surgery as another measure.

Complications vary with each type of treatment. The overall number of problems after the operation was the same for fusion as for replacement. Patients with a fusion of one wrist and a replacement in the other liked the new wrist joint the best. This is not a suprise. A wrist fusion often causes problems with personal hygiene and other common tasks. For example, fastening buttons is easier with a wrist replacement.

Newer designs of joint implants may change the future of wrist arthritis. Wrist fusion may give way to wrist replacement to give patients more motion and more function. Currently, replacing the wrist joint is more expensive and may not last as long as a wrist fusion.

The authors conclude that joint replacement will have to give patients better function than a fusion before wrist replacement surgery becomes the standard treatment choice.

You may think TWA is an airline. But in the orthopedic world, TWA stands for total wrist arthroplasty. TWA is a joint replacement for patients with pain and loss of wrist motion from arthritis. Most patients getting a TWA have rheumatoid arthritis, but some have osteoarthritis.

Early attempts at TWA were had a high rate of failure. Doctors at the Mayo Clinic in Rochester, Minnesota, rolled up their sleeves and went to work on the problem. This study reports the results of using a newer TWA design.

The Biaxial TWA has been used for the last 20 years. In the 1990s, the design was changed to include a longer metacarpal stem. This part of the implant fits further into the bone of the third finger. The stem is about 50 percent longer than in the original design. Researchers believed a longer stem would give greater stability. They thought it wouldn’t come loose as often as the shorter stem.

The authors of this study report good results using the Biaxial TWA with the long stem. All the patients had less pain after the operation. Overall motion was better, and everyone was satisfied with the results. No failures and no loose implants were reported. There were two cases of bone fracture in the middle finger, but this didn’t change the final outcome for those patients.

Researchers are still looking for ways to reduce the rate of failure with wrist implants. A new type of implant is being studied. It combines cobalt-chrome parts with a titanium coating on the joint surface. The authors report early results of no failures, but long-term studies are still needed.

Hip, knee, and even shoulder joint replacements have become very common. Replacing the wrist is more difficult because the wrist is a complex joint. It’s made of many small bones spaced unevenly in two rows. This arrangement gives the hand and fingers fine motor control and strength, but it makes wrist joint replacements much more difficult.

Wrist replacements have been around for 25 years, but they are still uncommon. The most likely cause of wrist problems leading to joint replacement is arthritis from a previous injury or trauma (called posttraumatic arthritis). Until recently, the best treatment for arthritis after trauma has been wrist fusion. In 1990, a group of doctors from France and Belgium called the Destot group designed a wrist implant. It was hoped that the new implant would keep more finger and hand function.

This study looks at the result of the Destot implant on range of motion and grip strength. Researchers set out to find patients who can benefit from the Destot implant. An implant is also known as a prosthesis. A group of 25 patients received the Destot prosthesis. After the operation, the patients reported a big decrease in pain levels. More than 80 percent were very happy with their results. Overall success was rated as excellent. Most patients said that they would have the same surgery again.

The Destot implant works best when used for posttraumatic wrist arthritis. These patients’ only other choice is a fusion. Nonmanual laborers are the best candidates for this type of wrist replacement, especially when they are over 50 years of age.

Wrist injuries from trauma or work and sports activities may be serious enough to require partial wrist fusion. This procedure is used to reduce wrist pain while preserving wrist movement. Such a combination is especially vital to professional athletes who have a limited number of years to earn a high income.

A partial fusion uses bone graft from one of the bones in the forearm to join three small wrist bones together: the scaphoid, the trapezium, and the trapezoid. These three bones form a triangle on the thumb side of the wrist. The fusion holds these bones in place when pressure or load is put on the wrist. Without the fusion, the scaphoid is free to slip out from beneath the nearby capitate bone.

Problems can occur with this treatment method. One concern is that the fusion causes forces to pass to the nearby wrist bones, producing arthritis in the joints formed by these bones.

Hand surgeons in Connecticut tracked 800 cases of partial fusions over a 27-year period. Each patient was tested for motion, grip and pinch strength, pain, and return to work. The rate of arthritis and other complications was also measured.

The authors report a good result (no wrist pain and 70 percent or more motion) in up to 90 percent of patients. An equal number of patients was able to return to their previous jobs. Less than two percent of all patients developed arthritis. These results were better than reported from previous studies.

The authors conclude that they had better than usual results for several reasons. The doctors prepared the bony surfaces before grafting, and they used pins to hold the graft together during healing. Patients were immobilized for six weeks after surgery. According to the doctors in this study, good surgical technique reduces complications with this type of wrist surgery.

You may not find a crystal ball in your doctor’s office, but sometimes the information doctors have gets close. This study offers one way to tell if a patient with carpal tunnel syndrome (CTS) could be helped by surgery. Getting relief from a steroid injection appears to be a good predictor of success for surgery.

CTS is a condition that is caused by pressure on (or damage to) the median nerve. This nerve travels down the arm and through a passageway formed of bones (the carpals) and ligaments in the wrist, called the carpal tunnel.

Taking the pressure off the median nerve by cutting the ligament over the tunnel is a well-known treatment. However, it doesn’t work for everyone. Patients and doctors like to know that an operation will help. The results of this study may give some answers to that question.

Steroid injections often help in cases of CTS where swelling is part of the problem. Sometimes an injection is all a patient needs to get better. Other patients get better for a while after the shot, but then their symptoms come back. Patients who feel relief, according to this and other studies, are most likely to be helped by surgery.

This study showed that the success rate of surgery is best for patients who’d gotten relief of symptoms with a steroid injection. No other predictor of success is known.

The authors of this study advise doctors to try a steroid injection with any patient who has CTS. It’s a simple treatment with few risks and low cost. The chances of success with surgery are less if symptoms are not relieved after an injection. In these cases, surgery may still be helpful for some patients and shouldn’t be avoided altogether.

Doctors continue to study the best ways to do various operations. Is it better to cut a joint open or to insert an arthroscope and avoid an open operation? The arthroscope is a slender tool with a tiny TV camera on the end that can be inserted into the joint. The doctor can see and carry out the operation with this device.

Researchers in Turkey and the US worked together to answer this question for Kienbock’s disease of the wrist. Kienbock’s is the loss of blood supply to the lunate bone in the wrist. Without enough blood, the bone starts to break down and collapses. Painful wrist motion and a decrease in strength is the common result.

Treating this condition has always been difficult for hand surgeons. It’s not clear what treatment is best. The “wait and see” approach used in the past didn’t work. Surgery is advised for more advanced cases. Which operation and how to do it remain unclear.

In this study, 16 patients were divided into two groups. One group had an open operation to put bone graft material into the damaged lunate. A nearby blood vessel was rerouted to the graft for improved healing.

The other group had arthroscopic surgery. Using an arthroscope, the doctor cleaned the area around the lunate, then fused the lunate to the bone next to it. Bringing an extra blood vessel to the area wasn’t part of group two’s treatment.

Group one (the open operation) had a faster time to fusion. Group two, however, had a shorter operation time, fewer days in the hospital, and faster return to daily activities. Both groups had a big increase in range of motion and grip strength, but these measures didn’t return to normal levels for either group.

The authors of this study showed that arthroscopic surgery is superior to an open operation for advanced cases of Kienbock’s disease. More studies are needed to see what happens years after this surgery. The use of arthroscopic surgery in earlier stages of the disease also needs further study.

Advances in MRI (magnetic resonance imaging) technology have improved the outcomes for some conditions. Kienbock’s disease is one of them. Kienbock’s disease was first described in 1910 by Dr. Kienbock. The condition is generally believed to be caused by a loss of blood supply to a bone in the wrist (lunate). The lost blood supply can cause bone death, called osteonecrosis.

Treatment can help stop the disease from getting worse. It can also eliminate pain and help keep normal hand and wrist function. Early treatment is very important. The specific steps taken depend on the stage of the disease. In its early stages, putting the arm in a cast is the first step. This gives the bone a chance to heal.

If the bone has already lost its blood supply, surgery will likely be needed. The dead or dying bone is removed and a new piece of bone is grafted in its place. The surgeon carefully looks for bone in the wrist to use as a donor piece. It must have a good blood supply.

Kienbock’s disease of the wrist occurs most often in men who do manual labor. Pain, stiffness, loss of motion, and death of the lunate bone are common problems. Without early treatment, the patient can lose function and risk permanent damage. MRI aids in detecting early signs of this bone disease, making early treatment possible.

The median nerve passes through the carpal tunnel in the wrist. The wrist bones (carpals) on one side and the flexor retinaculum on the other form the carpal tunnel. The flexor retinaculum is a thick ligament that crosses over the front of the wrist bones. Pressure on the median nerve can cause carpal tunnel syndrome (CTS). Doctors aren’t always sure what causes the pressure on the median nerve as it passes through the tunnel.

Symptoms of hand and finger pain or numbness and tingling can be treated with surgery. The doctor inserts a thin tube-like tool into the palm side of the wrist. This device is called an endoscope. It’s inserted under the skin and into the carpal tunnel.

Using this tool, the doctor is able to cut the thick ligament where it crosses over the median nerve. Cutting this ligament takes the pressure off the median nerve. Some doctors are concerned that putting the endoscope into the carpal tunnel adds even more pressure against the nerve.

A doctor in Belgium studied 20 middle-aged women with CTS. Measurements of the pressure inside the carpal tunnel were taken before and after the operation. The wrist was placed in several different positions while the pressure was recorded. Pressures were highest with the wrist in extreme positions. The pressure went down after the ligament was cut.

Carpal tunnel release can be done using an endoscope without causing more nerve compression. The pressure of the scope against the nerve isn’t much and it doesn’t last long. Releasing the ligament across the carpal tunnel takes the pressure off the nerve. Most patients get relief from their painful symptoms.

According to the author of this study, measuring the pressure before, during, and after surgery can help doctors. If the pressure is less than 30 mm Hg, then the ligament has been cut. Incomplete release of the ligament may cause symptoms to persist.