Bellapianta Orthopedics Wrist

They’re made of an incredible network of bones, cartilage, nerves, connective tissues and joint fluid — all working together to perform some of the strongest and most intricate movements on a daily basis. And yet, they’re surprisingly delicate. When your wrists hurt — whether from carpal tunnel, a sprain or worse — it often seems like you can’t focus on anything else.

Wrist pain can be caused by overuse, traumatic injuries, or arthritis and other diseases. Some issues can be treated at home with anti-inflammatory medications and hot or cold treatments, but you should always be checked out by a hand doctor first. Depending upon the severity of your condition, orthopaedic care may be needed to avoid long-term complications. Your treatment may range from physical therapy to corticosteroid injections to surgery.

Conditions of the Wrist

Our wrist is a complex joint made up of eight small bones arranged in two rows between the bones in your forearm and the bones in your hand. Tough bands of ligament connect your wrist bones to each other and to your forearm bones and hand bones. Tendons attach muscles to bones. Damage to any of the parts of your wrist can cause pain and affect your ability to use your wrist and hand.

Injuries

Sudden impacts. Wrist injuries often occur when you fall forward onto your outstretched hand. This can cause sprains, strains and even fractures. A scaphoid fracture involves a bone on the thumb side of the wrist. This type of fracture may not show up on X-rays immediately following the injury.

Repetitive stress. Any activity that involves repetitive wrist motion — from hitting a tennis ball or bowing a cello to driving cross-country — can inflame the tissues around joints or cause stress fractures, especially when you perform the movement for hours on end without a break. De Quervain's disease is a repetitive stress injury that causes pain at the base of the thumb.

Arthritis

Osteoarthritis. This type of arthritis occurs when the cartilage that cushions the ends of your bones deteriorates over time. Osteoarthritis in the wrist is uncommon and usually occurs only in people who have injured that wrist in the past.

Rheumatoid arthritis. A disorder in which the body's immune system attacks its own tissues, rheumatoid arthritis commonly involves the wrist. If one wrist is affected, the other one usually is, too.

Other Diseases and Conditions

Carpal tunnel syndrome. Carpal tunnel syndrome develops when there's increased pressure on the median nerve as it passes through the carpal tunnel, a passageway in the palm side of your wrist.

Ganglion cysts. These soft tissue cysts occur most often on the part of your wrist opposite your palm. Smaller ganglion cysts seem to cause more pain than larger ones do.

Kienbock's disease. This disorder typically affects young adults and involves the progressive collapse of one of the small bones in the wrist. Kienbock's disease occurs when the blood supply to this bone is compromised.

Scaphoid Fracture of the Wrist

A scaphoid (navicular) fracture is a break in one of the small bones of the wrist. This type of fracture occurs most often after a fall onto an outstretched hand. Symptoms of a scaphoid fracture typically include pain and tenderness in the area just below the base of the thumb. These symptoms may worsen when you try to pinch or grasp something.

Treatment for a scaphoid fracture can range from casting to surgery, depending on the fracture's severity and location on the bone.

Because portions of the scaphoid have a poor blood supply—and a fracture can further disrupt the flow of blood to the bone—complications with the healing process are common.

Anatomy

The wrist is formed by the two bones of the forearm—the radius and the ulna—and eight small carpal bones. The carpal bones are arranged in two rows at the base of the hand. There are four bones in each row.

The scaphoid bone is one of the carpal bones on the thumb side of the wrist, just above the radius. The bone is important for both motion and stability in the wrist joint. The word "scaphoid" comes from the Greek term for "boat." The scaphoid bone resembles a boat with its relatively long, curved shape.

The scaphoid bone can most easily be identified when your thumb is held in a "hitch-hiking" position. It is located at the base of the hollow made by the thumb tendons. Often referred to as the "anatomic snuffbox," this area is typically the site of tenderness or pain when a fracture occurs.

Description

A scaphoid fracture is usually described by its location within the bone. Most commonly, the scaphoid breaks in its mid-portion, called the "waist." Fractures can also occur at both the proximal and distal ends of the bone.

Scaphoid fractures are classified according to the severity of displacement--or how far the pieces of bone have moved out of their normal position:

Non-displaced fracture. In this type of fracture, the bone fragments line up correctly.

Displaced fracture. In this type of fracture, the bone fragments have moved out of their normal position. There may be gaps between the pieces of bone or fragments may overlap each other.

Cause

A scaphoid fracture usually occurs when you fall onto an outstretched hand, with your weight landing on your palm. The end of the larger forearm bone (the radius) may also break in this type of fall, depending on the position of the hand on landing.

The injury can also happen during sports activities or motor vehicle collisions.

Fractures of the scaphoid occur in people of all ages, including children.There are no specific risk factors or diseases that make you more likely to experience a scaphoid fracture. Some studies have shown that using wrist guards during high-energy activities like inline skating and snowboarding can help decrease your chance of breaking a bone around the wrist.

Symptoms

Scaphoid fractures usually cause pain and swelling in the anatomic snuffbox and on the thumb side of the wrist. The pain may be severe when you move your thumb or wrist, or when you try to pinch or grasp something.

Unless your wrist is deformed, it might not be obvious that your scaphoid bone is broken. With some scaphoid fractures, the pain is not severe and may be mistaken for a wrist sprain.

Pain in your wrist that does not go away within a day of injury may be a sign of a fracture—so it is important to see a doctor if your pain persists. Prompt treatment of a scaphoid fracture will help avoid potential complications.

Wrist Sprains

A wrist sprain occurs when the strong ligaments that support the wrist stretch beyond their limits or tear. This occurs when the wrist is bent or twisted forcefully, such as caused by a fall onto an outstretched hand. Wrist sprains are common injuries. They can range from mild to severe, depending on how much damage there is to the ligaments.

Description

Ligaments are strong, fibrous tissues that connect bones to other bones. The ligaments in the wrist help to keep the bones in proper position and stabilize the joint.

Sprains can range from a stretch or tiny tear in the fibers that make up the ligament to a complete tear through the ligament or through its attachment to the bone.

Grades of Wrist Sprains

Sprains are graded, depending on the degree of injury to the ligaments:

Grade 1 sprain (mild). The ligaments are stretched, but not torn.
Grade 2 sprain (moderate). The ligaments are partially torn. This type of injury may involve some loss of function.
Grade 3 sprain (severe). The ligament is completely torn or the ligament is pulled off of its attachment to bone. These are significant injuries that require medical or surgical care. If the ligament tears away from the bone, it may take a small chip of bone with it. This is called an avulsion fracture.

Cause

Wrist sprains are caused most often by a fall onto an outstretched hand. This might happen during everyday activities, but frequently occurs during sports and outdoor recreation.

Symptoms

A sprained wrist is painful. Other symptoms may include:

Swelling
Bruising
Tenderness to touch
A feeling of popping or tearing inside the wrist
A feeling of warmth around the wrist

Even a wrist injury that seems mild with minimal swelling could still involve a torn ligament and require surgery to avoid long-term problems.

Similarly, an unrecognized (occult) fracture can be mistaken for a mild or moderate sprain. If left untreated, the fracture may not heal properly and the patient could require a surgery that might have been avoided with early, appropriate treatment. The most common example of this is an occult fracture of the scaphoid, one of the small bones in the wrist.

It is important for your doctor to evaluate even a mild wrist injury if it does not improve quickly. This is especially important if the injury causes persistent wrist pain. Proper diagnosis and treatment of wrist injuries is necessary to avoid long-term problems, including chronic pain, stiffness, and arthritis.

Arthritis of the Wrist

Arthritis involves inflammation of one or more of your joints. Pain and stiffness are common symptoms of arthritis, and when these occur in your wrist, simple daily activities can become more difficult.

There are many types of arthritis, and most of these can affect the wrist. Although the severity of symptoms related to arthritis can vary, most arthritis-related diseases are chronic. This means that they are long-lasting—even permanent—and can eventually cause serious joint damage.

Your wrist is a complex joint—it is actually made up of multiple small joints. When healthy, the bones glide easily over each other during movement, protected by smooth cartilage that coats the joint surfaces. Arthritis damages this cartilage. As the disease progresses, there is a gradual loss of cartilage. Without a smooth joint surface, the bones rub against each other, leading to joint damage that cannot be repaired.

Although there is no cure for arthritis today, there are many treatment options available to help relieve your symptoms. Some options may also slow the progression of joint damage. With proper treatment, many people are able to manage their symptoms and stay active.

Anatomy

The wrist is a complex joint that connects the hand to the forearm. It is formed by the two bones of the forearm—the radius and the ulna—and eight small carpal bones. The carpal bones are arranged in two rows at the base of the hand. There are four bones in each row.

The joint surface of each bone is covered with articular cartilage—a slippery substance that protects and cushions the bones as you move your hand and wrist.

Description

Although there are many types of arthritis, the three that most commonly affect the wrist are:

Osteoarthritis
Rheumatoid arthritis
Posttraumatic arthritis

Osteoarthritis

Osteoarthritis can develop due to normal "wear-and-tear" in the wrist, particularly in people who have a family history of arthritis. It is a common problem for many people after they reach middle age, though it may occur in younger people, too.

In osteoarthritis, the smooth, slippery articular cartilage that covers the ends of the bones gradually wears away over time. Because the cartilage surface has little to no blood supply, it has little ability to heal or regenerate when it becomes injured or worn down.

As the cartilage wears away, it becomes frayed and rough, and the protective space between the bones decreases. This can result in bone rubbing on bone and lead to pain and stiffness in the joint.

Osteoarthritis in the wrist can also develop from Kienböck's disease. In Kienböck's disease, the blood supply to one of the carpal bones—the lunate—is disrupted, causing the bone to die and slowly collapse. Over time, this collapse can lead to changes and arthritis in the joints around the lunate.

Rheumatoid Arthritis

Rheumatoid arthritis is a chronic disease that can affect multiple joints throughout the body. The condition often starts in smaller joints, such as those found in the hand and wrist. It is symmetrical, meaning that it usually affects the same joint on both sides of the body.

Rheumatoid arthritis is an autoimmune disease. This means that the body's immune system attacks its own tissues. In rheumatoid arthritis, the defenses that normally protect the body from infection instead damage normal tissue (such as cartilage and ligaments) and can soften bone.

Rheumatoid arthritis often affects the joint between the two bones of the forearm, the radius and ulna. The deformity in the ulna can cause wearing and possible rupture of the tendons that straighten your fingers. This can cause more deformity and loss of function in your hand.

The exact cause of rheumatoid arthritis is not known—there are no clear genetic or environmental factors. Although it is not an inherited disease, researchers believe that some people have genes that could make them more likely to have rheumatoid disease.

Posttraumatic Arthritis

Posttraumatic arthritis can develop after an injury, such as a broken wrist bone or a torn ligament. This trauma can cause a direct injury to the cartilage or a delayed wearing of the cartilage due to a change in the way the bones move together—such as after a ligament tear.

Posttraumatic arthritis can develop over many years from the initial injury. Despite proper treatment, an injured joint is more likely to become arthritic over time.

Symptoms

Not all patients with arthritis will experience symptoms. When they do occur, the severity varies greatly from patient to patient. For some patients, the symptoms are not constant—but may come and go depending on their level of activity and other factors.

Symptoms of arthritis may include:

Pain
Swelling
Reduced range of motion or stiffness
Weakness in the joint

Elbow (Olecranon) Bursitis

Elbow bursitis occurs in the olecranon bursa, a thin, fluid-filled sac that is located at the boney tip of the elbow (the olecranon).

There are many bursae located throughout the body that act as cushions between bones and soft tissues, such as skin. They contain a small amount of lubricating fluid that allows the soft tissues to move freely over the underlying bone.

Normally, the olecranon bursa is flat. If it becomes irritated or inflamed, more fluid will accumulate in the bursa and bursitis will develop.

Cause

Elbow bursitis can occur for a number of reasons.

Trauma. A hard blow to the tip of the elbow can cause the bursa to produce excess fluid and swell.
Prolonged pressure. Leaning on the tip of the elbow for long periods of time on hard surfaces, such as a tabletop, may cause the bursa to swell. Typically, this type of bursitis develops over several months.
People in certain occupations are especially vulnerable, particularly plumbers or heating and air conditioning technicians who have to crawl on their knees in tight spaces and lean on their elbows. Certain athletic activities may also prompt the development of olecranon bursitis, such as long holds of the plank position.
Infection. If an injury at the tip of the elbow breaks the skin, such as an insect bite, scrape, or puncture wound, bacteria may get inside the bursa sac and cause an infection. The infected bursa produces fluid, redness, swelling, and pain. If the infection goes untreated, the fluid may turn to pus. Occasionally, the bursa sac may become infected without an obvious injury to the skin.
Medical conditions. Certain conditions, such as rheumatoid arthritis and gout, are associated with elbow bursitis.

Symptoms

Swelling. The first symptom of elbow bursitis is often swelling. The skin on the back of the elbow is loose, which means that a small amount of swelling may not be noticed right away. In many cases, the first sign of bursitis is swelling at the elbow.
Pain. As the swelling continues, the bursa begins to stretch, which causes pain. The pain often worsens with direct pressure on the elbow or with bending the elbow. The swelling may grow large enough to restrict elbow motion.
Redness and warm to the touch. If the bursa is infected, the skin becomes red and warm. If the infection is not treated right away, it may spread to other parts of the arm or move into the bloodstream. This can cause serious illness. Occasionally, an infected bursa will open spontaneously and drain pus.

Carpal Tunnel Syndrome

Carpal tunnel syndrome is a common condition that causes pain, numbness, and tingling in the hand and arm. The condition occurs when one of the major nerves to the hand — the median nerve — is squeezed or compressed as it travels through the wrist.

In most patients, carpal tunnel syndrome gets worse over time, so early diagnosis and treatment are important. Early on, symptoms can often be relieved with simple measures like wearing a wrist splint or avoiding certain activities.

If pressure on the median nerve continues, however, it can lead to nerve damage and worsening symptoms. To prevent permanent damage, surgery to take pressure off the median nerve may be recommended for some patients.

Anatomy

The carpal tunnel is a narrow passageway in the wrist, about an inch wide. The floor and sides of the tunnel are formed by small wrist bones called carpal bones.

The roof of the tunnel is a strong band of connective tissue called the transverse carpal ligament. Because these boundaries are very rigid, the carpal tunnel has little capacity to "stretch" or increase in size.

The median nerve is one of the main nerves in the hand. It originates as a group of nerve roots in the neck. These roots come together to form a single nerve in the arm. The median nerve goes down the arm and forearm, passes through the carpal tunnel at the wrist, and goes into the hand. The nerve provides feeling in the thumb and index, middle, and ring fingers. The nerve also controls the muscles around the base of the thumb.

The nine tendons that bend the fingers and thumb also travel through the carpal tunnel. These tendons are called flexor tendons.

Description

Carpal tunnel syndrome occurs when the tunnel becomes narrowed or when tissues surrounding the flexor tendons swell, putting pressure on the median nerve. These tissues are called the synovium. Normally, the synovium lubricates the tendons, making it easier to move your fingers.

Carpal tunnel syndrome is caused by pressure on the median nerve as it travels through the carpal tunnel.

Cause

Most cases of carpal tunnel syndrome are caused by a combination of factors. Studies show that women and older people are more likely to develop the condition.

Other risk factors for carpal tunnel syndrome include:

Heredity. This is likely an important factor. The carpal tunnel may be smaller in some people or there may be anatomic differences that change the amount of space for the nerve—and these traits can run in families.
Repetitive hand use. Repeating the same hand and wrist motions or activities over a prolonged period of time may aggravate the tendons in the wrist, causing swelling that puts pressure on the nerve.
Hand and wrist position. Doing activities that involve extreme flexion or extension of the hand and wrist for a prolonged period of time can increase pressure on the nerve.
Pregnancy. Hormonal changes during pregnancy can cause swelling.
Health conditions. Diabetes, rheumatoid arthritis, and thyroid gland imbalance are conditions that are associated with carpal tunnel syndrome.

Symptoms

Symptoms of carpal tunnel syndrome may include:

Numbness, tingling, burning, and pain—primarily in the thumb and index, middle, and ring fingers
Occasional shock-like sensations that radiate to the thumb and index, middle, and ring fingers
Pain or tingling that may travel up the forearm toward the shoulder
Weakness and clumsiness in the hand—this may make it difficult to perform fine movements such as buttoning your clothes
Dropping things—due to weakness, numbness, or a loss of proprioception (awareness of where your hand is in space)

In most cases, the symptoms of carpal tunnel syndrome begin gradually—without a specific injury. Many patients find that their symptoms come and go at first. However, as the condition worsens, symptoms may occur more frequently or may persist for longer periods of time.

Night-time symptoms are very common. Because many people sleep with their wrists bent, symptoms may awaken you from sleep. During the day, symptoms often occur when holding something for a prolonged period of time with the wrist bent forward or backward, such as when using a phone, driving, or reading a book.

Many patients find that moving or shaking their hands helps relieve their symptoms.

Ulnar Tunnel Syndrome of the Wrist

Ulnar tunnel syndrome occurs when the ulnar nerve is compressed at the wrist. The ulnar nerve is one of the three main nerves that provide feeling and function to the hand. It travels from your neck down into your hand, and can be constricted in several places along the way.

When pressure on the nerve occurs at the wrist, it causes numbness and tingling in the little finger and along the outside of the ring finger. In addition, ulnar tunnel syndrome can sometimes cause weakness of hand pinch and grip.

Cause

The most common cause of ulnar tunnel syndrome is a soft tissue tumor, usually a benign (noncancerous) cyst called a ganglion which originates from the wrist joint.

Other frequent causes are repetitive trauma or chronic pressure applied to the area of the hand. Repetitive trauma can result from the use of a jackhammer. Chronic pressure can occur in the hand of a bicyclist against the handlebars.

Symptoms

Symptoms develop gradually. Weakness and increasing numbness, particularly on the little finger side of the hand are usual signs of ulnar tunnel syndrome. The degree of weakness and numbness depends on the location of the pressure point. Pain may or may not be present.

As the syndrome progresses, it may become more difficult to open jars, hold objects, or coordinate the fingers during such tasks as typing or playing a musical instrument.

De Quervain's Tendinosis

De Quervain's tendinosis occurs when the tendons around the base of the thumb are irritated or constricted. The word "tendinosis" refers to a swelling of the tendons. Swelling of the tendons, and the tendon sheath, can cause pain and tenderness along the thumb side of the wrist. This is particularly noticeable when forming a fist, grasping or gripping something, or when turning the wrist.

Anatomy

Two of the main tendons to the thumb pass through a tunnel (or series of pulleys) located on the thumb side of the wrist. Tendons are rope-like structures that attach muscle to bone. Tendons are covered by a slippery thin soft-tissue layer, called synovium. This layer allows the tendons to slide easily through a fibrous tunnel called a sheath.

Any swelling of the tendons and/or thickening of the sheath, results in increased friction and pain with certain thumb and wrist movements.

Causes

De Quervain's tendinosis may be caused by overuse. It also is associated with pregnancy and rheumatoid disease. It is most common in middle-aged women.

Symptoms

Signs of De Quervain's tendinosis:

Pain may be felt over the thumb side of the wrist. This is the main symptom. The pain may appear either gradually or suddenly. Pain is felt in the wrist and can travel up the forearm. The pain is usually worse when the hand and thumb are in use. This is especially true when forcefully grasping objects or twisting the wrist.
Swelling may be seen over the thumb side of the wrist. This swelling may accompany a fluid-filled cyst in this region.
A "catching" or "snapping" sensation may be felt when moving the thumb.
Pain and swelling may make it difficult to move the thumb and wrist.

Ganglion Cyst of the Wrist and Hand

Ganglion cysts are the most common mass or lump in the hand. They are not cancerous and, in most cases, are harmless. They occur in various locations, but most frequently develop on the back of the wrist.

These fluid-filled cysts can quickly appear, disappear, and change size. Many ganglion cysts do not require treatment. However, if the cyst is painful, interferes with function, or has an unacceptable appearance, there are several treatment options available.

Description

A ganglion rises out of a joint, like a balloon on a stalk. It grows out of the tissues surrounding a joint, such as ligaments, tendon sheaths, and joint linings. Inside the balloon is a thick, slippery fluid, similar to the fluid that lubricates your joints.

Ganglion cysts can develop in several of the joints in the hand and wrist, including both the top and underside of the wrist, as well as the end joint of a finger, and at the base of a finger. They vary in size, and in many cases, grow larger with increased wrist activity. With rest, the lump typically becomes smaller.

Cause

It is not known what triggers the formation of a ganglion. They are most common in younger people between the ages of 15 and 40 years, and women are more likely to be affected than men. These cysts are also common among gymnasts, who repeatedly apply stress to the wrist.

Ganglion cysts that develop at the end joint of a finger — also known as mucous cysts — are typically associated with arthritis in the finger joint, and are more common in women between the ages of 40 and 70 years.

Symptoms

Most ganglions form a visible lump, however, smaller ganglions can remain hidden under the skin (occult ganglions). Although many ganglions produce no other symptoms, if a cyst puts pressure on the nerves that pass through the joint, it can cause pain, tingling, and muscle weakness.

Large cysts, even if they are not painful, can cause concerns about appearance.

Kienböck's Disease

Kienböck's disease is a condition where the blood supply to one of the small bones in the wrist, the lunate, is interrupted.

Bone is living tissue that requires a regular supply of blood for nourishment. If the blood supply to a bone stops, the bone can die. This is called osteonecrosis.

Damage to the lunate causes a painful, stiff wrist and, over time, can lead to arthritis.

Cause

The cause of Kienböck's disease is not known. Many people with Kienböck's disease think they have a sprained wrist at first. They may have experienced some form of trauma to the wrist, such as a fall. This type of trauma can disrupt the blood flow to the lunate.

Some things may put you more at risk for the disease. For example, most people have two vessels that supply blood to the lunate, but in some people there is only one source. This may slow the blood flow to the bone. In addition, if the two bones of the forearm (the radius and ulna) are different lengths, extra pressure can be put on the lunate during some wrist motions. Over time, this extra stress on the bone may lead to Kienböck's disease.

Symptoms

The most common symptoms of Kienböck's disease include:

A painful and sometimes swollen wrist
Limited range of motion in the affected wrist (stiffness)
Decreased grip strength in the hand
Tenderness directly over the bone (on the top of the hand at about the middle of the wrist)
Pain or difficulty in turning the hand upward

Wrist Arthroscopy

Arthroscopy is a surgical procedure used to diagnose and treat problems inside a joint.

Arthroscopy utilizes a small fiber optic instrument called an arthroscope that enables the surgeon to see inside the joint without making large incisions into the muscle and tissue.

The wrist is a complex joint with eight small bones and many connecting ligaments. Arthroscopic surgery can be used to diagnose and treat a number of conditions of the wrist, including chronic wrist pain, wrist fractures, ganglion cysts, and ligament tears.

Description

The surgeon makes small incisions (called portals) through the skin in specific locations around a joint.

These incisions are less than half an inch long. The arthroscope, which is approximately the size of a pencil, is inserted through these incisions. The arthroscope contains a small lens, a miniature camera, and a lighting system.

The three-dimensional images of the joint are projected through the camera onto a television monitor. The surgeon watches the monitor as he or she moves the instrument within the joint.

Probes, forceps, knives, and shavers at the ends of the arthroscope are used to correct problems uncovered by the surgeon.

Diagnostic Arthroscopy

Diagnostic arthroscopy might be used if it is not clear what is causing wrist pain. It might also be used if wrist pain continues for several months despite nonsurgical treatment.

Before arthroscopic surgery, your doctor will do the following.

Perform a physical examination of the hand and wrist
Learn more about past medical conditions or concerns (medical history)
Perform tests that locate the pain (provocative tests). These tests involve moving the hand in order to reproduce the pain.
Secure images of the hand and wrist. These may include x-rays, magnetic resonance imaging (MRI) scans, or an arthrogram (an x-ray taken after a dye is injected into the joint).

Usually, arthroscopic surgery requires only that the hand and arm are numbed (regional anesthesia). A sedative may be given to further relax the patient.

Two or more small incisions (portals) are made on the back of the wrist. The arthroscope and instruments are inserted through those portals and the joint is observed through the camera on the end of the arthroscope.

After the surgery, the incisions are closed with a small stitch and a dressing is applied. Sometimes a splint is used.

Arthroscopic Surgical Treatment

Arthroscopic surgery can be used to treat a number of conditions of the wrist.

Chronic wrist pain. Arthroscopic exploratory surgery may be used to diagnose the cause of chronic wrist pain when the results of other tests do not provide a clear diagnosis. Often, there may be areas of inflammation, cartilage damage, or other findings after a wrist injury. In some cases, after the diagnosis is made, the condition can be treated arthroscopically as well.
Wrist fractures. Small fragments of bone may stay within the joint after a bone breaks (fractures). Wrist arthroscopy can remove these fragments, align the broken pieces of bone, and stabilize them by using pins, wires, or screws.
Ganglion cysts. Ganglion cysts commonly grow from a stalk between two of the wrist bones. During an arthroscopic procedure, the surgeon can remove the stalk, which may reduce the change that these cysts will return.
Ligament/TFCC tears. Ligaments are fibrous bands of connective tissue that link or hinge bones. They provide stability and support to the joints. The TFCC is a cushioning structure within the wrist. A fall on an outstretched hand can tear ligaments, the TFCC, or both. The result is pain with movement or a clicking sensation. During arthroscopic surgery, the surgeon can repair the tears.
Carpal tunnel release. Carpal tunnel syndrome is characterized by numbness or tingling in the hand, and sometimes with pain up the arm. It is caused by pressure on a nerve that passes through the carpal tunnel. (The carpal tunnel is formed by the wrist bones and a thick tissue roof.) Pressure can build up within the tunnel for many reasons, including irritation and swelling of the tissue (synovium) that covers the tendons. If the carpal tunnel syndrome does not respond to nonsurgical treatment, one option is to repair the area surgically. The surgeon would cut the ligament roof and enlarge the tunnel. This would reduce pressure on the nerve and relieve symptoms. This can sometimes be done using an arthroscope.

After Surgery

For the first 2 or 3 days after surgery, the wrist should be elevated and the bandage should be kept clean and dry. Ice may help keep swelling down. There are exercises that can be used to help maintain motion and rebuild your strength. Although pain after surgery is usually mild, analgesic medications will help relieve any pain.

Kienböck's Disease Treatment

Although there is no complete cure for Kienböck's disease, there are several nonsurgical and surgical options for treating it. The goals of treatment are to relieve the pressure on the lunate and to try to restore blood flow within the bone.

Nonsurgical Treatment

In the very early stage of the disease, pain and swelling may be managed with anti-inflammatory medications, such as aspirin or ibuprofen. Immobilizing your wrist for a period of time can help relieve pressure on the lunate, and your doctor may recommend splinting or casting for 2 to 3 weeks.

It is important to monitor any changes in your symptoms during the early stage of Kienböck's disease. If the pain is not relieved with simple treatments or it returns, your doctor may recommend surgery.

Surgical Treatment

There are several surgical options for treating Kienböck's disease. The choice of procedure will depend on several factors, in particular how far the disease has progressed. Additional factors to consider are the patient's activity level, personal goals, and the surgeon's experience with the procedures.

Revascularization. In some cases, it may be possible to return the blood supply to the lunate bone. This procedure is called revascularization. It is more successful during early phases of the disease — stages 1 and 2 — before the lunate has significantly deteriorated.

Revascularization involves removing a portion of bone with attached blood vessels from another bone — most often a forearm bone (radius) or an adjacent bone in the hand. This piece of bone with its blood supply is called a vascularized graft. It is inserted into the lunate bone.

To help the bones stay in place during healing, an external fixator may be temporarily applied. This is a metal device that is attached to the outside of the wrist with pins that insert into the bones. It can relieve pressure on the lunate while the graft is healing and restoring a blood supply.

Joint leveling. If the two bones of the lower arm are not the same length, a joint leveling procedure may be recommended. Bones can be made longer using bone grafts or shortened by removing a section of the bone. This leveling procedure reduces the forces that compress the lunate and often stops the progression of the disease.

Proximal row carpectomy. If the lunate is severely collapsed or broken into pieces, it can be removed. In this procedure, the two bones on either side of the lunate are also removed. This procedure, called a proximal row carpectomy, will relieve pain while maintaining partial wrist motion.

Fusion. To ease pressure on the lunate, nearby wrist bones can be fused together to make one, solid bone. A fusion can be partial, in which just some of the bones are fused together. This procedure relieves pain and retains some wrist motion.

If the disease has progressed to severe arthritis of the wrist, fusing all of the bones of the wrist to the radius will relieve pain and and improve hand function. Although all wrist motion is eliminated in a complete fusion, forearm rotation is preserved.

Outcomes

Kienböck's disease varies considerably in its severity, as well as its rate of progression. Each patient's response to treatment depends on the degree of damage to the lunate and surrounding wrist bones. Some patients may require more than one procedure if the disease continues to progress.

In summary, patients with Kienböck's disease should not expect to ever return to normal wrist function after any treatment. However, treatment gives the greatest opportunity for long-term preservation of function and pain relief.

Carpal Tunnel Syndrome Treatment

Although it is a gradual process, for most people carpal tunnel syndrome will worsen over time without some form of treatment. For this reason, it is important to be evaluated and diagnosed by your doctor early on. In the early stages, it may be possible to slow or stop the progression of the disease.

Nonsurgical Treatment

If diagnosed and treated early, the symptoms of carpal tunnel syndrome can often be relieved without surgery. If your diagnosis is uncertain or if your symptoms are mild, your doctor will recommend nonsurgical treatment first.

Nonsurgical treatments may include:

Bracing or splinting. Wearing a brace or splint at night will keep you from bending your wrist while you sleep. Keeping your wrist in a straight or neutral position reduces pressure on the nerve in the carpal tunnel. It may also help to wear a splint during the day when doing activities that aggravate your symptoms.
Nonsteroidal anti-inflammatory drugs (NSAIDs). Medications such as ibuprofen and naproxen can help relieve pain and inflammation.
Activity changes. Symptoms often occur when your hand and wrist are in the same position for too long—particularly when your wrist is flexed or extended.
If your job or recreational activities aggravate your symptoms, changing or modifying these activities can help slow or stop progression of the disease. In some cases, this may involve making changes to your work site or work station.
Nerve gliding exercises. Some patients may benefit from exercises that help the median nerve move more freely within the confines of the carpal tunnel. Specific exercises may be recommended by your doctor or therapist.
Steroid injections. Corticosteroid, or cortisone, is a powerful anti-inflammatory agent that can be injected into the carpal tunnel. Although these injections often relieve painful symptoms or help to calm a flare up of symptoms, their effect is sometimes only temporary. A cortisone injection may also be used by your doctor to help diagnose your carpal tunnel syndrome.

Surgical Treatment

If nonsurgical treatment does not relieve your symptoms after a period of time, your doctor may recommend surgery.

The decision whether to have surgery is based on the severity of your symptoms—how much pain and numbness you are having in your hand. In long-standing cases with constant numbness and wasting of your thumb muscles, surgery may be recommended to prevent irreversible damage.

Surgical Procedure

The surgical procedure performed for carpal tunnel syndrome is called a "carpal tunnel release." There are two different surgical techniques for doing this, but the goal of both is to relieve pressure on your median nerve by cutting the ligament that forms the roof of the tunnel. This increases the size of the tunnel and decreases pressure on the median nerve.

In most cases, carpal tunnel surgery is done on an outpatient basis. The surgery can be done under general anesthesia, which puts you to sleep, or under local anesthesia, which numbs just your hand and arm. In some cases, you will also be given a light sedative through an intravenous (IV) line inserted into a vein in your arm.

Open carpal tunnel release. In open surgery, your doctor makes a small incision in the palm of your hand and views the inside of your hand and wrist through this incision. During the procedure, your doctor will divide the transverse carpal ligament (the roof of the carpal tunnel). This increases the size of the tunnel and decreases pressure on the median nerve.

After surgery, the ligament may gradually grow back together—but there will be more space in the carpal tunnel and pressure on the median nerve will be relieved.

Endoscopic carpal tunnel release. In endoscopic surgery, your doctor makes one or two smaller skin incisions—called portals—and uses a miniature camera—an endoscope—to see inside your hand and wrist. A special knife is used to divide the transverse carpal ligament, similar to the open carpal tunnel release procedure.

The outcomes of open surgery and endoscopic surgery are similar. There are benefits and potential risks associated with both techniques. Your doctor will talk with you about which surgical technique is best for you.

Recovery

Immediately following surgery, you will be encouraged to elevate your hand above your heart and move your fingers to reduce swelling and prevent stiffness.

You should expect some pain, swelling, and stiffness after your procedure. Minor soreness in your palm may last for several weeks to several months.

Grip and pinch strength usually return by about 2 to 3 months after surgery. If the condition of your median nerve was poor before surgery, however, grip and pinch strength may not improve for about 6 to 12 months.

You may have to wear a splint or wrist brace for several weeks. You will, however, be allowed to use your hand for light activities, taking care to avoid significant discomfort. Driving, self-care activities, and light lifting and gripping may be permitted soon after surgery.

Your doctor will talk with you about when you will be able to return to work and whether you will have any restrictions on your work activities.

Outcomes

For most patients, surgery will improve the symptoms of carpal tunnel syndrome. Recovery, however, may be gradual and complete recovery may take up to a year.

If you have significant pain and weakness for more than 2 months, your doctor may refer you to a hand therapist who can help you maximize your recovery.

f you have another condition that causes pain or stiffness in your hand or wrist, such as arthritis or tendonitis, it may slow your overall recovery. In long-standing cases of carpal tunnel syndrome with severe loss of feeling and/or muscle wasting around the base of the thumb, recovery will also be slower. For these patients, a complete recovery may not be possible.

Occasionally, carpal tunnel syndrome can recur, although this is rare. If this happens, you may need additional treatment or surgery.

Distal Radius Fractures (Broken Wrist) Treatment

Treatment of broken bones follows one basic rule: the broken pieces must be put back into position and prevented from moving out of place until they are healed.

There are many treatment options for a distal radius fracture. The choice depends on many factors, such as the nature of the fracture, your age and activity level, and the surgeon's personal preferences.

Nonsurgical Treatment

If the broken bone is in a good position, a plaster cast may be applied until the bone heals.

If the position (alignment) of your bone is out of place and likely to limit the future use of your arm, it may be necessary to re-align the broken bone fragments. "Reduction" is the technical term for this process in which the doctor moves the broken pieces into place. When a bone is straightened without having to open the skin (incision), it is called a closed reduction.

After the bone is properly aligned, a splint or cast may be placed on your arm. A splint is usually used for the first few days to allow for a small amount of normal swelling. A cast is usually added a few days to a week or so later, after the swelling goes down. The cast is changed 2 or 3 weeks later as the swelling goes down more, causing the cast to loosen.

Depending on the nature of the fracture, your doctor may closely monitor the healing by taking regular x-rays. If the fracture was reduced or thought to be unstable, x-rays may be taken at weekly intervals for 3 weeks and then at 6 weeks. X-rays may be taken less often if the fracture was not reduced and thought to be stable.

The cast is removed about 6 weeks after the fracture happened. At that point, physical therapy is often started to help improve the motion and function of the injured wrist.

Surgical Treatment

Sometimes, the position of the bone is so much out of place that it cannot be corrected or kept corrected in a cast. This has the potential of interfering with the future functioning of your arm. In this case, surgery may be required.

Procedure. Surgery typically involves making an incision to directly access the broken bones to improve alignment (open reduction).

Depending on the fracture, there are a number of options for holding the bone in the correct position while it heals:

Cast
Metal pins (usually stainless steel or titanium)
Plate and screws
External fixator (a a stabilizing frame outside the body that holds the bones in the proper position so they can heal)
Any combination of these techniques

Open fractures. Surgery is required as soon as possible (within 8 hours after injury) in all open fractures. The exposed soft tissue and bone must be thoroughly cleaned (debrided) and antibiotics may be given to prevent infection. Either external or internal fixation methods will be used to hold the bones in place. If the soft tissues around the fracture are badly damaged, your doctor may apply a temporary external fixator. Internal fixation with plates or screws may be utilized at a second procedure several days later.

Recovery

Because the kinds of distal radius fractures are so varied and the treatment options are so broad, recovery is different for each individual. Talk to your doctor for specific information about your recovery program and return to daily activities.

Pain Management

Most fractures hurt moderately for a few days to a couple of weeks. Many patients find that using ice, elevation (holding their arm up above their heart), and simple, non-prescription medications for pain relief are all that are needed to relieve pain.

Your doctor may recommend combining ibuprofen and acetaminophen to relieve pain and inflammation. The combination of both medications is much more effective than either one alone. If pain is severe, your doctor may suggest a prescription-strength medication, such as an opioid, for a few days.

Be aware that although opioids help relieve pain after surgery, they are a narcotic and can be addictive. It is important to use opioids only as directed by your doctor. As soon as your pain begins to improve, stop taking opioids. Talk to your doctor if your pain has not begun to improve within a few days of your surgery.

Cast and Wound Care

In some cases, original casts will be replaced because swelling has gone down so much that the cast becomes loose. The last cast is usually removed after about 6 weeks.

During healing, casts and splints must be kept dry. A plastic bag over the arm while showering should help. If the cast does become wet, it will not dry very easily. A hair dryer on the cool setting may be helpful.

Most surgical incisions must be kept clean and dry for 5 days or until the sutures (stitches) are removed, whichever occurs later.

Potential Complications

After surgery or casting, it is important that you achieve full motion of your fingers as soon as possible. If you are not able to fully move your fingers within 24 hours due to pain and/or swelling, contact your doctor for evaluation.

Your doctor may loosen your cast or surgical dressing. In some cases, working with a physical or occupational therapist will be required to regain full motion.

Unrelenting pain may be a sign of Complex Regional Pain Syndrome (Reflex Sympathetic Dystrophy) which must be treated aggressively with medication or nerve blocks.

Rehabilitation and Return to Activity

Most people do return to all their former activities after a distal radius fracture. The nature of the injury, the kind of treatment received, and the body's response to the treatment all have an impact, so the answer is different for each individual.

Almost all patients will have some stiffness in the wrist. This will generally lessen in the month or two after the cast is taken off or after surgery, and continue to improve for at least 2 years. If your doctor thinks it is needed, you will start physical therapy within a few days to weeks after surgery, or right after the last cast is taken off.

Most patients will be able to resume light activities, such as swimming or exercising the lower body in the gym, within 1 to 2 months after the cast is removed or within 1 to 2 months after surgery. Vigorous activities, such as skiing or football, may be resumed between 3 and 6 months after the injury.

Long-Term Outcomes

Recovery should be expected to take at least a year.

Some pain with vigorous activities may be expected for the first year. Some residual stiffness or ache is to be expected for 2 years or possibly permanently, especially for high-energy injuries (such as motorcycle crashes), in patients older than 50 years of age, or in patients who have some osteoarthritis. However, the stiffness is usually minor and may not affect the overall function of the arm.

Finally, osteoporosis is a factor in many wrist fractures. It has been suggested that people who have a wrist fracture should be tested for bone weakness, especially if they have other risk factors for osteoporosis. Ask your doctor about osteoporosis testing.