News Category: Wrist

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.

Tempted by job or hobby, the hands of carpal tunnel syndrome sufferers don’t know when to quit. Repetitive wrist motions can often lead the ruinous way from pain and tingling to lasting problems.

Short of surgery, treatments traditionally have included resting the wrist, wearing a splint, taking anti-inflammatory medications, and receiving steroid injections into the wrist. Steroid injections are thought to reduce swelling in the carpal tunnel and ease pressure on the affected nerve.

Studies have been done to see how effective steroid injections can be and whether they can prevent the need for carpal tunnel surgery. For the most part, past research has shown that some people get relief for a while, but steroids aren’t a “cure.” In this study, about half the people who got relief after an injection ended up having symptoms again within 18 months.

To test whether steroid injections could help, the researchers enrolled 30 people whose tests were positive for carpal tunnel syndrome. Five people had problems in both wrists, so the study actually included injection treatments for 35 wrists.

After getting an injection, patients were instructed to wear a special wrist splint at all times for two weeks. They were also told to put the splint on again if the symptoms returned after two weeks.

Four checkups were scheduled over the next 18 months. The researchers tallied the results during each follow-up visit by asking patients how their wrists felt. Only a third of the wrists were reportedly doing better after three months. And at the end of the study period, only 11 percent were still feeling relief.

After measuring these poor long-term results, the researchers concluded that steroid injections shouldn’t be viewed as a routine treatment choice in the conservative treatment of carpal tunnel syndrome.

Fractures of the scaphoid–the small wrist bone near the base of the thumb–are the most common kind of injury to the small bones of the wrist (the carpals). Unless the bone has been completely moved out of place, casts are the tried-and-true way of mending scaphoid injuries. But a cast can take eight to 12 weeks to heal the fracture, and the wrist sometimes stays stiff after the cast is off, delaying return to work or sports. Is there a faster way to get the bone to heal?

In this study, researchers wanted to see whether an internal type of fixation–namely putting a screw into the broken bone–would get people back on the job more quickly than a cast. The study involved 25 active-duty military personnel who had fractured their scaphoid bone. The patients were mostly men around the age of 24. Fourteen of them wore a cast until their fractures healed. The other 11 had surgery to stabilize their wrists with a screw.

Patients who had surgery got better faster than those who only wore a cast. The patients in the surgery group healed in about seven weeks, as opposed to 12 weeks for patients with casts. Patients who had surgery were back on the job in eight weeks, compared to 15 weeks for the cast group. In other words, screw fixation cut recovery time nearly in half.

Both treatments had similar results when compared two years later. Patients in both groups had a nearly equal amount of movement in the wrist, had nearly equal grip strength, and were equally satisfied with their treatment.

From these results, the short-term outlook is that the screw provides a faster fix for fractures of the scaphoid bone. However, the authors caution that surgery is not for everyone. More research is needed to determine the risks and benefits of screw fixation for fractures of the scaphoid bone.

Smoking has been shown to interfere with the success of spine and ankle surgeries. Researchers think nicotine restricts the blood supply that bones in these areas need in order to heal. Compared to the spine and ankle, the wrist naturally has a better blood supply. Does smoking also affect the results of wrist surgery?

In this study, the authors compared the results of smokers and nonsmokers who had surgery on the ulna,the bone on the little-finger side of the wrist. The patients had been having problems in the part of the wrist where the end of the ulna meets the hand.

After trying other kinds of treatment such as splints and anti-inflammatory drugs, the patients in the study had osteotomy surgery on the ulna bone. This is a procedure in which a wedge of bone is taken out of the ulna, shortening it. Doctors use a metal plate to connect the two pieces of bone together. When this procedure is successful, the two ends of the ulna grow back together into solid bone. The authors wanted to see whether smokers would have a harder time healing than nonsmokers. 

Thirty-nine patients had surgery. Nineteen were smokers. Twenty were not. Compared to nonsmokers, smokers took almost twice as long to heal. The average time for bones to grow back together was 7.1 months for smokers and 4.1 months for nonsmokers.

Smoking also decreased the overall success of the surgery. Six of the smokers showed serious delays in healing (more than seven months) or failed to show any improvement in a year’s time. Meanwhile, none of the nonsmokers had these problems.

This study adds to the already abundant evidence that smoking impairs bone healing. Notably, nicotine works its mischief on bones that are trying to grow together, even in an area with good blood supply. The authors want to find ways to improve bone union for smokers who have wrist surgery. Implanting bone in the wrist or keeping casts on longer after surgery may help patients who smoke get better results from this procedure.

You’ve probably seen some of the fancy computer keyboards on the market. Split keyboards are just one of the many innovative styles available today. They come in two sections that divide the keyboard in half. By angling the two sections just right, your wrists are able to stay in line with your forearms, so they don’t bend outward as you type. Are these keyboards just showy office accessories, or do they really make a difference to your wrists?

In this study, 11 experienced women typists tried out four different keyboard setups. One setup was a split keyboard with the keys lined up like a regular keyboard. The three other setups used were split keyboards that had the two sections separated by different distances and angles. While the women typed, researchers recorded the position of their wrists, as well as their typing speed and accuracy.

The typists worked with the same speed and accuracy at each of the keyboards. However, they kept a much healthier wrist position when the two sections were angled compared to when they were lined up like a regular keyboard.

Lots of wrist problems can start when the wrist bends outward. This awkward strain can irritate and inflame the wrist tendons (tendonitis) and the covering around the tendons (tenosynovitis). The further the wrist bends outward, the greater the pressure inside the carpal tunnel. This can put the median nerve inside the tunnel at risk. A mere 20 degree wrist angle can pump the pressure twice as high as the amounts that can cause harm to the median nerve.

All the typists said they felt equally comfortable at all of the workstations. They experienced a little more neck discomfort at the regular keyboard than at the split keyboards, but this difference was so slight that it wasn’t felt to have much practical significance.

Looks like those fancy keyboards do make a difference after all. If you don’t have any wrist or carpal tunnel problems, you can use a split keyboard to ease strain on your wrist and perhaps avoid future wrist problems from using your keyboard. More research is needed to find out if the split keyboard can be arranged just right to help people who’ve already been dealing with severe wrist problems.

Carpal tunnel syndrome (CTS) has become one of the most common job-related injuries. About 1.9 million American workers develop CTS each year. It causes enormous disruptions for workers and employers, and the financial impacts are huge.

For the most part, workers tend to think that medical treatment offers little help for their CTS. They especially doubt that surgery can help. But according to a recent study of Workers Compensation cases, these perceptions are wrong.

The study compared the results of surgical and conservative treatment of CTS in 182 Workers Compensation cases. Surgery was performed on just over half of these patients. The rest received conservative treatment. The authors conclude that both kinds of treatment are effective. Overall, 82% of the workers returned to full employment. The others retained some disability.

However, workers who underwent surgery had even less disability than workers who received only conservative treatment. Over 87% of the workers who had surgery returned to work with no disability. This compares to about 75% of the workers who got conservative treatment. In both cases, patients who had severe CTS were less likely to recover completely.

The authors’ main conclusion is that surgery seems to be the most effective way to treat occupational CTS. And surgery is possibly more cost-effective for the injured workers, their employers, and the Workers’ Compensation system.