News Category: Wrist

Even the simplest surgery can be expensive. Doctors are sensitive to the costs of surgery. They look for ways to simplify treatment while still keeping it effective. This is the case with surgery for ganglions in the hand or wrist.

A ganglion is a thin sac that contains a thick, clear fluid. The fluid looks and feels like hardened jelly. Ganglions can occur in the hands and feet, usually in the lining of the tendons. They may cause pain and prevent you from gripping items. For these reasons, they are sometimes removed.

A new way to treat ganglions is available. Instead of removing it with an open surgery, doctors are using a method called aspiration. During aspiration, a needle is inserted into the ganglion. This either pops the ganglion or allows the doctor to remove the thick fluid.

More than half of all patients require only one aspiration. The cost is around $150. Sometimes, a second aspiration is needed. This doubles the cost (now around $300). Even with two aspirations, the cost is less than surgery to remove the ganglion. Surgical removal costs around $1,800. Rarely, surgery is required after two aspirations.

Some injuries that are rare in adults are starting to show up in children. This may happen because of increased participation in sports and increased intensity of play. Wrist fracture is one of the potential injuries that may result from a fall onto the hand or having blunt trauma to the wrist.

At the base of the thumb are the radius (radial) bone of the forearm and the scaphoid bone of the wrist. When the thumb is stuck out in a hitchhiker’s pose, there is a dent in the skin at the bottom of the thumb. This is called the “snuffbox.” The scaphoid bone is inside this space. Nonhealing fractures of this bone in children have now been reported for the first time. Doctors at Children’s Hospital in Boston reported three cases between 1993 and 1996.

When the scaphoid bone is broken, the blood supply may be cut off, causing the bone to slowly die. Surgery is needed to remove the dead bone and replace it with a live bone graft. One method of bone graft is to take the donor bone from the radial bone just above the thumb. Wires are used to hold the graft in place until it heals. This method improves healing.

Painful wrist symptoms that last months after a fall on the hand could be from a broken scaphoid bone. Delayed diagnosis can occur because this is a rare injury in children. Doctors may expect to see more injuries of this type in children as the sports craze continues.

Carpal tunnel syndrome (CTS) is a common problem when the median nerve inside the wrist gets pinched, squeezed, or damaged. In fact, CTS is the most common nerve problem reported in the United States. Symptoms are usually wrist and hand pain, numbness, and clumsiness using the hands. Some patients have writer’s cramp, muscle fatigue, or sensitivity to cold in the fingers. In severe cases, there is weakness and wasting of the hand muscles.

The doctor uses the symptoms and several tests to diagnose CTS. Diagnosis can be difficult, especially when the symptoms are not the usual pain and numbness. Sometimes doctors order electrodiagnostic tests. These tests are used to stimulate muscles and nerves to see how well they are working.

Electrodiagnostic tests are an important part of the process to find CTS. However, only about half of the patients tested this way actually have CTS. This has led researchers to look for better ways to predict who has CTS and who needs this kind of testing.

They looked at symptoms of patients who had positive electrical results. Five symptoms were found that are predictors of abnormal electrodiagnostic tests. These include symptoms at night, symptoms that last several months to one year or more, numbness and tingling, and thumb muscle weakness and wasting. The presence of these symptoms will help doctors know when to send someone for electrodiagnostic tests.

Patients who break the bone on the thumb side of the forearm (the radius) may have less arm movement later. This is because bones sometimes shorten during healing. As a result, patients may have trouble rotating the arm. This can make it difficult to do everyday tasks.

Doctors have designed a special splint to improve arm movement after radius fracture. When you think of a splint, you may think of a device that keeps a limb from moving. Not so with a dynamic splint. This kind of splint actually increases movement by placing gentle, sustained force on the affected limb. The splint can enhance forearm rotation. Patients tighten the tubing around the outside of the splint to get a nonpainful stretch that improves the arm’s flexibility over time.

Fifteen patients with radius fractures that had healed properly wore dynamic splints. The patients had tried regular hand therapy without success in regaining full forearm movement. Patients wore splints six to 12 hours a day for about three months.

Treatment with dynamic splints improved patients’ forearm movement by more than 50 percent. Before treatment with the splint, only half of the patients had good forearm rotation. After treatment, all but one patient had good or excellent rotation. None of the patients lost movement during the year after treatment.

Before treatment, patients’ forearm rotation in the outward direction, or supination, was particularly poor. It is important to correct this in order to prevent future shoulder problems. Splinting improved supination in all but four patients. Patients who did not improve did not wear their splint regularly, waited too long to start treatment, or developed other problems, such as bony growths.

Dynamic splints improve forearm rotation after radius fracture when other treatments have failed. These splints seem to have good results for a variety of fractures when used as directed within a few months of injury.

Wrist fractures can be tricky to treat. A break in the bone at the end of the forearm (the radius) can be especially difficult. With this kind of fracture, the surface of the wrist joint can become damaged, leading to early problems of arthritis. Sometimes the bone collapses. Surgery is often required. Until recently, this surgery was complicated. Pins, screws, and wires were needed to hold the bones together.

A new paste injected into the joint simplifies surgery. The paste surrounds the bone defect and hardens in 12 hours. This man-made substance is called synthetic graft.

When this graft material was first invented, it was injected into bone fractures. Now doctors are injecting the paste between the broken sections of bones where joints are formed. The bones are lined up and held together without pins or wires. Most patients wear a special device after surgery that holds the wrist still for four to six weaks, called an external fixator. This method gives the patient less pain and better motion once the fixator is taken off.

An injectable bone substitute can be used to repair wrist fractures affecting the joint surface. The material works like a paste and quickly hardens around the bone. This simplifies surgery and healing.

Wrist fractures can be very difficult to treat. Sometimes the bone breaks into several pieces. Sometimes the bone moves apart after it breaks. Getting the bone back together and lined up properly requires complicated surgery. Even with surgery, the two sides of the wrist joint don’t always match up. This can lead to pain, swelling, and loss of wrist motion.

Doctors in Switzerland have noticed fewer problems when surgery is done from the palm side of the wrist. With this method, called the palmar approach, it’s easier to move tendons out of the way. There is also more space for the plate that holds the bones together. This method of surgery is used when the broken bone moves toward the palm side of the wrist. Movement of bone after a break is called displacement.

When the wrist bone breaks, the bone can move in the opposite direction, toward the back of the wrist. Bone displacement toward the back of the hand is much more difficult to repair. Damage to the tendons, nerves, and blood vessels is more common when the back of the wrist has to be opened up.

These doctors tried the palmar approach for wrist fractures with bone moving toward the back of the hand. A special plate with pegs and screws was designed just for this surgery. It was tested in a laboratory and found to be three times stronger than other plates already in use.

The results of this experiment were very good. The break healed faster, and there were fewer steps in surgery. There was less tendon disruption, and the joint matched up better. Faster return to normal wrist strength and motion is possible with this new approach.

Arthrography is one way doctors diagnose wrist pain. By injecting the wrist with a special substance, doctors can see problems in the wrist that may be causing symptoms. Recently, this method has been put under the microscope. Some think arthrography finds problems where there are none, or locates problems in the wrong places. Others have noted that arthrography misses problems that are then identified by arthroscopy, a technique that uses a small TV camera to see under the skin. Can arthrogram results be trusted? If your wrist arthrogram comes out “normal,” what does it mean?

These doctors wanted to see how people with normal wrist arthrograms were doing at least two years later. They surveyed 42 patients who had inconclusive physical exams, and normal arthrogram and X-ray results. The patients averaged 26 years old. They had experienced symptoms for about a year. Most of them had a specific wrist injury. Others had clicking or grinding in the wrist. The kind of arthrogram used was single injection. (Triple injection has come into use more recently, with more accurate results.)

After getting normal arthrography results, patients were treated with splints, anti-inflammatory medication, and activity modification. They did not have surgery.

Patients were followed up about six years after arthrography. Compared to people with no history of wrist symptoms, the patients in this study had more problems doing daily activities. These activities included opening a tight jar, doing heavy household chores, carrying objects over 10 pounds, and doing recreational activities that involved the hand or arm. Mild pain, stiffness, and weakness of the wrist were also common. However, these problems were fairly low overall. Nearly half of the patients had no real day-to-day problems because of their wrists. Also, wrist problems didn’t affect patients’ physical or mental well-being.

Most patients (64 percent) said their wrists had improved. Nineteen percent said their wrists were the same. Seventeen percent were worse. The longer patients had symptoms before arthrography, the more likely they were to have poor outcomes. Having a workers’ compensation claim at the time of arthrography didn’t affect patients’ outcomes.

Most patients with wrist pain who have inconclusive physical exams, normal X-rays, and normal arthrograms do well without surgery. A small percentage of patients continue to have problems. Whether these problems would be better served by another diagnostic procedure or treatment is unknown. For now, arthrography seems to be a useful tool in diagnosing wrist pain.

Wrist injuries are commonly a result of trauma, such as a sports injury. These injuries are named according to location. Other wrist injuries occur as a result of aging and the degenerative changes that come with it. These are named both by location and severity.

Many surgeons are particularly interested in wrist injuries involving the triangular fibrocartilage complex (TFCC). This structure is as complex as it sounds. The TFCC is a maze of cartilage and ligaments where the ulna bone on the inside edge of the forearm meets the small bones of the wrist. Tough, fibrous structures weave around and between the bones to hold everything together yet still allow movement.

The TFCC plays an important part in the workings of the wrist and the entire arm. Heavy and repeated wrist actions cause significant forces through the TFCC and upward into the forearm. Any change in the bones and ligaments in this area can cause problems.

A tear in which the TFCC pulls away from the end of the ulna bone is called a “Class 1B” tear. Surgery to repair this kind of tear has been a challenge for surgeons. It requires threading numerous sutures and tying many knots inside the joint, which makes the procedure time consuming. In addition, damage to the nearby tendons and nerves can occur.

A group of German surgeons used a procedure for repairing knees and adapted it for repairing tears of the TFCC. The new method only takes five minutes and avoids any risk to the nearby tendons and nerves. Surgeons use a simple clip or T-shaped device normally used to hold the cartilage in the knee together.

This procedure can be done using an arthroscope, an instrument that inserts into the joint. The arthroscope has a tiny TV camera on the end that lets doctors see inside the joint. This allows surgeons to pass the fixation device into the wrist without having to open the wrist joint. This little device also eliminates all the sutures and knots that were such a problem.

Doctors are always looking for ways to improve surgical procedures. With the help of an arthroscope and a clip previously used in knee surgery, wrist surgery for TFCC tears can be reduced from 30 to five minutes with virtually no complications.

When carpal tunnel syndrome (CTS) affects both wrists and hands, it is called bilateral CTS. Is it better to operate on one wrist at a time, or treat both wrists at once? Which approach is best in terms of return to work? And what kind of anesthesia should patients have for this surgery: local (only the area is numb), general block (entire arm is numb), or general (patient is asleep)?

To help answer these questions, surgeons studied two groups of patients with bilateral CTS. One group had surgery on one wrist at a time. This is called a staged procedure. The other group had both wrists operated on at once. The surgeons then compared the outcomes.

Surgery was safely performed with local anesthesia. There were many advantages to having both wrists operated on at the same time. For patients who had both wrists treated at once, recovery time was reduced. Medical costs were also reduced with only one hospital visit. And there were fewer doctor visits. Patients who had both wrists treated at once didn’t have to decide whether to work between surgeries. Time and paperwork devoted to return-to-work issues was much less. For these reasons, many doctors recommend operating on both wrists at once for bilateral carpal tunnel syndrome.

Have you ever heard of “washerwoman’s sprain”? This painful condition of the hand and wrist was common 100 years ago among women who made a living washing clothes. Today, it goes by another name: “de Quervain’s disease.” The name has changed, but the problem remains the same.

Repetitive motions can bring on de Quervain’s, especially a sideways motion of the wrist while gripping or using the fingers. This movement may cause painful irritation, swelling, and thickening of the tendons between the thumb and wrist.

Anyone using this motion can develop de Quervain’s, but some people are more likely to get it than others. For example, assembly-line workers, musicians, skiers, and hairdressers are at risk. Women are affected 10 times more often than men. The reason for this may be differences in anatomy. Normally, there are two tendons that pass through a tunnel at the base of the thumb, called a compartment. Many women with this condition have a second compartment, one for each tendon. More contact around each tendon could explain why de Quervain’s occurs more often in women.

Treatment for this condition involves rest, splints, and medication. Sometimes surgery is also needed. None of these options is acceptable to musicians though–especially professional pianists. Rest and splints are too time-consuming. And surgery alters the ability to play a full octave (stretching the little finger and thumb over eight keys).

An alternate treatment is the injection of corticosteroid medication into the affected area. In most cases, only one injection is needed. The pianist can usually return to work within three days. A second injection may be needed if pain and swelling persist. If a person has two compartments, the medication may not get to the sore tendon. The authors specifically injected the medication into the side of the thumb tendons within the compartment. Nearly all the patients in the study got relief after just one injection.

Pianists and other musicians do not have to give up their careers because of painful hand symptoms. When pain and swelling are caused by de Quervain’s disease, treatment may be simple. A single injection of corticosteroid medication can return the player to the piano or other instrument in a matter of days. There are no major complications of this treatment, only happy musicians tickling the ivories.

If you say the name “Colles” (pronounced “call-eez”), most doctors automatically think “wrist fracture.” Dr. Abraham Colles first described this type of fracture in 1814. A Colles fracture is a break at the end of the radius bone within 1.5 inches of the wrist joint. (The radius is one of two bones in the forearm that attaches to the wrist.)

After all these years, doctors still use the term “Colles fracture.” However, this term describes a range of injuries. Often there is more damage than just the break in the bone. In more than one-third of all cases, there is injury to the joint surfaces or connecting ligaments, or damage to the small wrist bones. Today’s medicine requires a better, more specific way to classify these types of injuries.

A better naming or classification system would help guide treatment. It would also give doctors a way to predict treatment results. If a fracture is not treated properly, serious problems may result. The bones may shorten. Joints may become stiff and painful. Arthritis may develop down the line.

Treatment for Colles fractures has changed over the years. Doctors now use an arthroscope to see inside the joint and decide when surgery is needed. Plaster casts and other means of immobilizing the wrist have been replaced by other methods. New methods keep the bones together while still allowing wrist movement.

Devices called external fixators use surgical pins to hold the bones in place during healing. Fixators have improved over the years to allow for wrist motion and prevent joint stiffness. However, these devices can lead to problems. Sometimes patients develop nerve or tendon damage, hand and finger stiffness, or even fractures of the fingers. A newer method of injecting a calcium-based glue into the joint is under trial. So far, studies show this to be just as good as using pins to fix the bones in place.

Treatment of Colles wrist fractures has advanced in the last 180 years. A more specific way of naming these fractures would allow doctors to compare different treatment methods for similar injuries. This would help doctors decide the best way to treat each type of fracture.

Carpal tunnel syndrome (CTS) is a fairly well-known condition. The carpal tunnel is a passage in the wrist formed by the wrist (carpal) bones and a band of ligament across the front called the retinaculum. The median nerve and tendons that flex or bend the wrist and thumb go through this tunnel. Anything that puts pressure on the nerve can cause the pain, numbness, and tingling of CTS.

Most cases of CTS can be treated with good results. Thank goodness, because treatment back in the 1800s was amputation! Today, doctors are trying to decide which surgery works best and how much treatment is really necessary. Sometimes CTS requires a two-step method of surgery. The surgeon opens the skin over the wrist and cuts the retinaculum that goes over the median nerve. Then the lining around the tendons is removed. This process is called tenosynovectomy.

But what if both steps aren’t really needed? Doctors noticed that when the lining or sheath around the tendons was removed and inspected. Although it looked thick, it was otherwise perfectly normal. There was no inflammation of the tendon sheath causing CTS.

A study was done to see if it’s possible to tell which patients need to have the tendon sheath removed. Eighty-eight patients were examined before surgery and followed for at least a year afterward. These patients were compared to patients who only had surgery to remove the ligament across the nerve. This second group of patients did not have the tendon sheath removed.

In both groups, symptoms and function improved equally after surgery. There seemed to be no link between the symptoms present and the condition of the tendon sheath.

Until now, most researchers thought CTS was caused by thickening and inflammation of the tendons in the carpal tunnel area. This study shows that increasing the space in the carpal tunnel by removing the tendon sheath does not change the patient’s symptoms. As a result, surgeons at that research hospital are no longer routinely removing the tendon sheath during carpal tunnel surgery.

Treatment of some medical conditions is not the same around the globe. In Japan, cultural and religious practices prevent the collection and banking of bone for use in surgery. Japanese surgeons have found ways around this problem.

A cancerous tumor was found in the radius bone of the forearm of a 50-year-old Japanese woman. Various treatments are available for this kind of cancer, but not all methods are available in Japan. Instead of removing the bone and replacing it with healthy bone from a bone bank, a different approach was used.

The tumor and a section of bone around it were removed. The bone was treated with radiation while outside the body, a procedure called extracorporeal irradiation. The bone was returned to the body and attached with a special plate to hold it in place. Two tendons had to be removed, but the surrounding ligaments were saved and reattached. This is not the first choice for treatment because of possible complications, but it was available, relatively easy, and saved the arm.

This technique has been used successfully in a small number of cases. Complications can include infection, death of the bone, bone resorption, or problems with the joint. In this case, there was a lack of bone union between the reimplanted bone and the remaining bone. Further surgery was needed, with more bone taken from the patient’s hip. The final result was good. The arm was saved, and there was no cancer two years later.

Different approaches to cancer and surgery for bone cancer are sometimes necessary. Bone banks may not be available in cetain countries. When bone has to be removed because of a tumor, it can be treated with radiation and returned to the body. There are problems with this method, but it can be used successfully.

You just had an X-ray taken of a very painful wrist. The X-ray technician comes back and tells you that one more view is required. This time you have to turn your hand and forearm in the very position that hurts the most. Is this really necessary?

Actually, doctors who read X-rays (radiologists) are asking the same question. Radiologists have studied cadavers (human bodies preserved for study) to determine correct positions for X-rays. From these studies, doctors decided that one X-ray of the wrist had to be done with the hand in a neutral position. The shoulder and elbow had to be in specific positions as well.

X-rays of the wrist are often taken with the forearm slightly rotated. This places the hand in a palm down position. When this happens by mistake, a second X-ray is needed. In the next X-ray, the wrist and forearm must be in a neutral position–or so say cadaver studies.

These researchers decided to conduct X-ray studies on human volunteers to see whether the cadaver findings hold true in live arms. The researchers thought there would be a difference in the position of bones in a live arm because of muscle forces. A study of 15 healthy adults was done to find out how important slight differences in hand placement might be. X-rays were taken of the wrist in three different positions. The space difference between the ends of two forearm bones in the wrist was measured.

The results were a bit tricky to interpret. The difference in the position of the bones was considered significant in research terms. However, the researchers pointed out that a statistical difference isn’t necessarily an important difference in the clinical setting. Getting another X-ray with the forearm and wrist in a neutral position may not be necessary after all.

Results for “normal” subjects might not be the same as those for patients with wrist problems. Maybe the bones would move differently if the person was in pain or unable to move easily. Age or sex may also make a difference.

It’s important for radiologists to know if the standard arm positions used in X-rays are giving them the information they need. Since these positions were decided on cadavers, it’s time to study them on live human subjects. More studies will be done to explore this issue.

Kienböck’s disease happens when a small wrist bone, the lunate, loses its blood supply. The bone begins to die, leading to a condition called avascular necrosis.

With Kienböck’s disease, the two bones in the forearm that control wrist rotation may grow to different lengths. The radius, which is on the thumb side of the forearm, may get longer than the ulna on the little-finger side. Kienböck’s disease has often been treated by surgically “leveling” or evening out these bones–either shortening the radius or lengthening the ulna where the bones meet in the wrist.

These authors have a new surgical treatment for Kienböck’s disease. They simply make a “window” in the radius and/or ulna for blood to flow through. But does this “decompression” procedure reduce pain and restore movement in the wrist?

Twenty-two patients had this procedure. Sixteen patients were male; six were female. Their average age was 36. About half were manual laborers. The other half had office jobs. All of the patients had pain and poor movement in one of their wrists. Their Kienböck’s disease was early to moderate.

There were no complications from surgery, and no patients had more surgery. Many patients had almost immediate pain relief. Six to 16 years after surgery (average 10 years), 91 percent of them had less pain than before surgery. Sixteen of them (72 percent) were completely pain-free. Four had only mild pain from time to time. One patient had moderate pain, and one had severe pain. With these two exceptions, all of the patients were able to go back to their former jobs.

Wrist movement and strength also improved. At follow-up, range of movement in the wrists that were operated on was 77 percent of patients’ opposite wrists. And grip strength was 75 percent. These results were on par with those of other surgical treatments for Kienböck’s disease.

Follow-up X-rays showed that 17 of the 22 patients were at the same stage of disease as they had been before surgery. Two patients had improved, and three had gotten worse. In general, the position of bones in the forearms and wrists stayed the same after surgery. However, blood flow seemed to improve over the follow-up period, as shown by MRI for a small set of patients.

There were no differences between patients who had both the radius and ulna treated with the decompression procedure, and the three patients who only had the radius treated. The authors think that working on the radius alone, or the radius in combination with the ulna, helps improve blood flow to the wrist. This can happen without changing the length of the bones.

The authors conclude that this simple surgery gives lasting pain relief. The results are similar to those of the bone leveling procedures. However, because the decompression procedure has fewer complications and doesn’t involve bone implants, it is especially noteworthy. More research is needed to understand exactly how this and other surgeries improve blood flow in patients with Kienböck’s disease.

A good workout can cause muscles to bulge. Now there’s proof that the median nerve in the wrist bulges when the hand gets a workout. Using a pair of scissors is enough to enlarge this nerve where it passes inside the carpal tunnel of the wrist. Formed by ligaments and bones, the carpal tunnel encloses eight finger tendons, a thumb tendon, and the median nerve.

Investigators think the added nerve size is from fluid that builds up around the nerve and from blood that flows into “reserve” vessels in the nerve. These reserve vessels are believed to stay empty until there’s activity or injury in the nerve.

An ultrasound machine was used to see the size of the median nerve in the wrists of 40 people. Comparing 19 men and 21 women, researchers observed that women tended to have smaller nerve canals. And women had larger median nerves on average than men.

Participants used scissors to repeatedly cut small pieces of doweling for five minutes. Ultrasound measurements were taken after each person completed the activity, and again five and ten minutes later.

Ten minutes after cutting, all participants still showed marked enlargement in the median nerve. But women averaged significantly greater increases in nerve size. Women had an increase of 17.6 percent; men showed only a 2.7 percent enlargement. None of the participants complained of pain, numbness, or tingling in the 24-hour period following the cutting activity.

The researchers feel the increased nerve size is normal and begins to go away shortly after the activity. Again, they believe this change is due to extra blood and fluid that fills in and around the nerve during certain hand actions. They suggest that more studies are needed to determine how hand activities affect the median nerve in the wrist.

Have you ever heard of Kienböck’s disease? Sounds like something you might get from eating too much German sausage! Actually, Kienböck’s disease is the softening of a particular bone in the wrist called the lunate. This disease was first described 90 years ago by Dr. Kienböck.

The lunate bone is located in the very center of the wrist. This bone normally gets its blood supply from a very small artery. The blood vessel only enters the bone on one side. When injury–especially a break (fracture) in the lunate bone–occurs, blood to the area can be completely cut off. When this happens, the bone starts to die, a condition called avascular (without blood) necrosis (death).

Many different operations are used to treat this condition. No single method has been successful for all cases. One 20-year-old woman’s year-long problem with right wrist pain and difficulty writing finally led her to see her doctor. She could not remember any specific injury. New scanning technology showed a small fracture in the lunate bone of her wrist.

A small piece of bone with a good blood supply was used to replace the dying bone. It was taken from the bone in the palm of the hand that connects with the index finger. After removing the dead part of the lunate, the replacement bone was carefully fitted into the remaining lunate bone. This way, the new bone could get a direct connection to the artery in that part of the wrist.

Other operations for this condition have reduced pain and improved movement, but the bone is often not repaired or restored. Moving a piece of bone with a good supply of blood to the center of the wrist is a new idea. It must be done when the damaged bone is still able to repair itself by receiving a new source of blood.

Are you feeling pins and needles or numbness and tingling in your hands or fingers? A condition called carpal tunnel syndrome (CTS) may be the culprit. CTS is now the most common cause of hand numbness at night and wrist pain during the day.

Symptoms of CTS can be felt when there is pressure on the median nerve as it travels through the bones of the wrist. This can occur for many reasons such as pregnancy, obesity, tumors, poor posture, neck problems, thyroid conditions, or even lack of vitamin B. The most common theory about how it is caused relates to work. Jobs that require the same hand or wrist motion over and over pose a risk for nerve problems.

How common is CTS in the United States? Researchers don’t really know. Estimates vary from a low of one in 1,000 people to a high of one in 100. A large study was done to see how many people in the general population have unreported and untreated symptoms. Surveys were mailed to 1,559 members of health centers located in four regional shopping centers. Based on these results, it looks like CTS is more common than previously reported. CTS may affect as many as three of every 100 people.

More and more people are reporting symptoms that can come from CTS. Some physicians call this an epidemic, meaning lots of people seem to have the same condition in the same geographical area. However, not all numbness and tingling in the fingers or pain in the wrist or hand are caused by CTS.

In view of this “epidemic,” the authors insist that accurate examination and diagnosis are needed to separate patients who truly have carpal tunnel syndrome from those who don’t. Doctors who make this effort will maximize the number of patients getting the correct treatment for their condition.

If you have arthritis pain in your wrist that doesn’t go away, your doctor may want to operate. Joint fusion, also called arthrodesis, stabilizes joints and gets rid of wrist pain when options are limited for patients with wrist arthritis. Unfortunately, this procedure can reduce mobility in the wrist. Doctors have seen this effect when they fuse the joint formed by the radius, the bone on the thumb side of the forearm, and the scaphoid, the largest bone on the thumb side of the wrist. The connection of the radius with the scaphoid is called the radioscaphoid joint.

Is there a way to operate and avoid a stiff wrist? These authors thought so. They believed that the scaphoid was the bone limiting movement after surgery. By taking out part of the scaphoid, they hoped to free up movement in the wrist.

They tested this model on the wrists of five cadavers. The authors mimicked the effect of joint fusion by fixing the cadavers’ radioscaphoid joints with special wire. X-rays were used to measure wrist flexibility both up and down, and side to side. Next, the authors removed part of the scaphoid bone farthest from the radioscaphoid joint. Then they measured wrist movement again.

After joint fusion, wrist movement up and down was less than half of what it was before surgery. Side to side movements were also much less after the procedure.

But when the far edge of the scaphoid was taken out, movement in the wrist improved considerably. Up and down movements approached normal at 122 degrees. This was a 106 percent improvement over movement after the joint was fused. Side to side movements increased to 43 degrees, a 32 percent improvement.

The main increase in movement occurred in the mid-section of wrist bones (the midcarpal joint). The authors think the scaphoid blocks movement in this part of the wrist by forming a bony “bridge.” When the far end of the scaphoid is taken out, the midcarpal joint is released and more movement is possible. In this study, the midcarpal joint accounted for 86 percent of the improvement in up and down movements of the wrist.

Taking out part of the scaphoid is a simple step that makes a big difference. This procedure could get rid of the wrist stiffness that often goes along with fusion of the radioscaphoid joint. The next step is to test the procedure on patients who suffer from arthritis in this joint.

The radius is the forearm bone that connects to the thumb-side of the wrist. If you break this bone where it joins the wrist, there are a few ways to treat your injury. External fixation is one of them. Surgeons use an external fixator to hold the bones in place from the outside using special pins. One type of fixator keeps the wrist from moving. Another, called a dynamic fixator, allows you to move your wrist right after surgery. Once the bones have healed, the pins and device are removed.

These authors prefer a dynamic fixator, so their patients can begin working on wrist mobility soon after surgery. However, this treatment may not stabilize the wrist enough for it to heal properly. A bone graft may have to be implanted to join the broken bones together. Rather than using bone from the patients’ own body, which can lead to other complications, these authors experimented with a bone substitute called hydroxyapatite (HA).

Twenty-five patients participated in the study. Fifteen were women; 10 were men. Their ages ranged from 19 to 75, with an average of 49. Most of the patients had injured their wrists in a fall.

During surgery, patients were placed in the external fixator; they also had a block of HA implanted at the fracture site. Small pieces of HA were used to fill the space between the block and surrounding bone. Wrist and hand movement was encouraged soon after surgery. At six weeks, the pins were removed. Patients were followed up two to four years after surgery (average = 2.5 years).

At follow-up, patients’ wrists showed good range of motion in all directions. For patients who injured their dominant hand, grip strength recovered to 89 percent of that of the other hand. For patients whose nondominant hand was involved, grip strength recovered to 73 percent. All but one of the wrists were classified as “excellent.” The remaining wrist was “good.”

X-rays showed that the block of HA healed to the surrounding bone within two to three months of surgery. In general, the alignment of bones after surgery was good. There were no complications from surgery, and no patients showed signs of arthritis. 

The authors suggest that HA has several advantages over bone from the patient’s body. To use patients’ own bone, a second part of the body has to be operated on. This brings the risk of infection, pain fracture, or nerve injury. HA works well as a substitute. It is better able to bond with bone than bone cement. Even older patients with osteoporosis had good results from the HA block plus external fixation. 

Inserting small pieces of HA around the block made healing happen three months faster than using the HA block alone. Getting the bones and joints to line up also made a big difference in helping people get back to their normal activities.