I cut a nerve! What now?

“I’d like to show my prowess, be a lion, not a mouwess, if I only had the nerve”

Cowardly Lion from “The Wizard of Oz”

It’s been a long sabbatical from the blog but I think I’ve come up with some new ideas to share.  I’ll be trying to add a new topic each month and if there are any topics you would like to discuss please contact me at richard.smith@orthotennessee.com and I will try to incorporate those into future posts.

One of the most serious injuries a person can suffer is a cut or laceration of a nerve to the hand or arm.  Nerve injuries can be difficult to repair and the outcome of the surgery depends on a lot of factors, many of which are out of the control of either the patient or the surgeon.  If you have had a laceration to a nerve I hope I can provide some information that will help you understand the injury and give you reasonable expectations about what can happen.

Nerves are probably the most complicated tissue in the body.  The nervous system connects us with our environment and allows us to interact with the world.  In the hand and upper extremity nerves have two main functions.  First, they provide us with sensation so that we can feel the things we touch.  Second, they power the muscles that allow us to move and manipulate our joints providing us the means to perform all the activities we want to do.  These functions are intertwined, since optimal muscle function requires excellent sensation.  Nerves also have a third function in that they control many autonomic (or automatic) functions of the hand such as sweating, hair growth and swelling.

The nerve itself is made up of nerve fibers that run from the hand to the spinal cord and then to the brain and back, and connective tissue that protects the nerve and gives the nerve some elasticity or the ability to stretch.  Each nerve fiber runs through a connective tube that helps protect the nerve as well.  In addition blood vessels run along the course of the nerve to supply nutrients to the nerve.

When a nerve is cut several things occur.  First, because of the elasticity of the tissue the nerve ends always separate when they are cut.  Second, the nerve reacts by basically trying to heal itself.  Unfortunately since the nerve ends are never close enough together the nerve can’t heal itself unless it is put back together with surgery.  If the nerve ends aren’t repaired the ends of the nerve will eventually form balls of scar tissue and nerve fibers that can be painful and sensitive.

Under ideal circumstances a nerve should be repaired within several days after injury.  It is certainly not an emergency, but a delay beyond a week or two can effect the ability to repair the nerve end to end.  The best injuries to repair are sharp lacerations that would occur by a knife.  Less ideal are nerves cut by saw blades or nerves that separated during a crushing type injury.

Other structures are often injured along with the nerve.  Tendons, bones, ligaments and skin and soft tissue injures can complicate the treatment plan.  All things being equal and assuming that there are no other major complications, then nerve surgery has a very simple goal: to align the two nerve ends as close as possible.  This is usually done with some very small suture that is probably about the size of a hair.  Most of the time the best results are obtained when the surgeon uses and operating microscope, although this is not necessary.  If there has been a delay in treating the injury, or if the nerve has been crushed or damaged to some degree, then a gap may develop between the two nerve ends.  The surgeon may have to use a piece of nerve call a nerve graft to bridge the gap between the two ends of the nerve.  After the surgery that arm usually has to be splinted for a period of time to allow the nerve ends to heal.

Once the nerve is repaired the healing process has only begun.  It takes about a month for the ends of the nerve to heal, and then the nerve fibers start growing down the nerve through the tubules I described earlier.  The goal of surgery is to get these tubules as close together as possible, but even the best nerve surgeon can only approximate the two ends of the nerve.  The nerve doesn’t grow too fast, maybe an inch a month under the best circumstances.  So you can see that if you cut a nerve near the elbow it may be two years or more before the nerve fibers could grow down to the hand.

There are several factors that affect nerve recovery.  Age is the most important.  The younger the patient the better the ability of the nerve to recover.  I have seen some amazing results in children and young adults.  However as we age the ability of our nerves to heal so that by the time we get older it’s difficult to get a nerve to heal well.  The closer the nerve is to the place it’s trying to get, the better the result will be.  A nerve cut in the finger has a better chance of recovering than a nerve cut in the wrist, for instance.  Also, if the nerve has only one function (sensation or motor), then the chances of recovery are better.  Some nerves have both motor and sensory functions and it’s harder to get all of those fibers lined up and headed in the right direction.  Also, if all the tissues around the nerve are healthy the nerve has a better chance of recovering.

Given all these factors I see a wide variation in recovery after nerve surgery.  I would recommend that if you have a choice of your surgeon try to choose someone who has experience in repairing nerves and is comfortable using a microscope.  No nerve surgeon has perfect results but there is probably an advantage to having an experienced surgeon with these injuries.

I certainly hope you never have to deal with this type of injury but if you do I think the information I’ve provided can help you understand what you are dealing with.

Nerve compression other than carpal tunnel syndrome

“Yeah runnin’ down a dream that never would come to me, working on a mystery, goin’ wherever it leads, runnin’ down a dream”

Tom Petty “Runnin’ Down a Dream”

Well I took a little sabbatical here to get some new ideas and add to the blog.  In honor of the late great Tom Petty, who died this month, our topic song is from his great album “Full Moon Fever”.  Everyone seems to know about Carpal Tunnel Syndrome, but there are actually a couple of other areas in the upper extremity where nerves can be compressed and cause problems such as numbness or weakness.

There are three major nerves in the arm and all three of them have specific areas where they can be compressed.  The most common area of course is carpal tunnel syndrome where the median nerve is compressed at the wrist.  However a more rare form of compression of the median nerve can occur further up the arm closer to the elbow.  Near the elbow the median nerve passes between a pretty big muscle called the pronator teres.  Very rarely the nerve can be pinched as it passes through the pronator and cause pain and discomfort in the arm.  The pain is usually pretty vague and does not always occur at night.  Occasionally patients will have numbness and tingling as well that can mimic carpal tunnel syndrome.  If the patient has carpal tunnel like symptoms of numbness and tingling and also has pain in the forearm near the elbow, then I have to think about the possibility of the median nerve being compressed further up the arm rather than at the carpal tunnel in the wrist.  There are ways of examining a patient to help make the diagnosis and occasionally a nerve conduction study will reveal the area of compression.  This problem may well get better on its own with rest and a cortisone shot may or may not help.  Rarely surgery is indicated to try and release the pressure on the nerve.

There is a variation of this problem where the thumb and index finger may quit bending due to irritation of a branch of the median nerve call the anterior interosseous nerve.  This is a scary problem because the patients can’t bend the tip of the thumb or the index finger.  Unfortunately there’s not much that can be done for this problem other than waiting for it to resolve.  Most of the recent studies don’t seem to show much improvement with surgery which is done to try and release pressure on the nerve.  It can sometimes take 6 months or longer for the nerve to recover so this takes a lot of patience from both the patient and the physician.

The ulnar nerve is another nerve that can be compressed.  This is your “funny bone” on the inside of your elbow, and pressure on the nerve at the elbow is the second most common area of compression in the upper extremity.  The latin word for elbow is “cubital” so this is known as cubital tunnel syndrome.  The most common symptom of cubital tunnel syndrome is numbness and tingling the pinky and the ring finger (carpal tunnel usually involves the thumb, index and middle fingers).  Patients may also notice weakness or clumsiness when using their hands because the ulnar nerve goes to the small muscles in the hands which contribute to our dexterity.  The most common cause of this problem is compression on the nerve as it passes around the elbow and goes through a tunnel of muscle.  A lot of the time this problems just goes away on it’s own.  It’s really hard to splint the elbow and cortisone shots don’t seem to do much good.  If the symptoms are really causing a problem or if numbness or muscle weakness have occurred then sometimes surgery is indicated.  There are a number of procedures than can be done, from simply releasing the nerve from the constricting areas to moving the entire nerve to get it away from the places where it is getting pinched.

Very rarely the ulnar nerve can be compressed in the wrist as well in an area right next to the carpal tunnel called guyon’s canal.  I’ve found in a significant number of patients who have this problem they usually have a small cyst or mass that is pressing on the nerve which needs to be removed as well as releasing the compression on the nerve.

The third major nerve to the arm is called the radial nerve and a branch of this nerve called the posterior interosseous nerve can be compression near the elbow.  This is usually on the top outside part of the elbow and can mimic tennis elbow.  This problem is known as radial tunnel syndrome.  The pain is usually not as specific as tennis elbow and the area that is really sore is a different from tennis elbow.  If I suspect the nerve is compressed I usually recommend an injection of cortisone and a numbing agent.  The problem will usually improve with an injection, although this may be temporary and the problem may need surgery to remove pressure from the nerve.

Fortunately these problems are pretty rare.  I will occasionally see patients with both carpal and cubital tunnel syndrome, and I see a fair number of patients with cubital tunnel syndrome, but the other problems are things that I see only a couple of times a year.  A good hand surgeon will be aware of these rare problems and hopefully can help guide you through if you develop one of these problems.

 

 

Arthritis in my elbow? What can i do?

“It’s a mess ain’t it sheriff?”  “If it ain’t it’ll do til the mess gets here”

from the movie “No Country for Old Men”

Arthritis can occur in any joint in the body.  Arthritis is very common in the hands, a little less common in the wrist, and even less common in the elbow.  Nonetheless elbow arthritis can be a painful process that can be difficult to treat.  In other blogs I have discussed the treatment of arthritis in the hands and the wrist, so now I would like to look at the elbow and try to give an update on how arthritis of the elbow can be treated.

The main problem people have when they get arthritis in the elbow is pain, although the main problem may be stiffness.  Most people notice a soreness in their elbows that gets worse with use and activity.  Usually the pain is worse with just about any activity, which helps to distinguish arthritis from the most common causes of elbow pain, which is elbow tendonitis (tennis elbow and golfers elbow).  In elbow tendonitis there are usually very specific motions and activities which cause the pain.  In addition, people with elbow arthritis usually lose a little bit of mobility while people with tennis and golfers elbow rarely lose motion.  The pain in arthritis is usually deeper, and more of an aching pain versus the shaper discomfort on tendonitis.  Sometimes people will feel a pulling or popping inside of their joint.

The most common type of arthritis in the elbow is osteoarthritis, although patients with rheumatoid arthritis will often have problems with their elbow.  Patients with rheumatoid arthritis usually have multiple joints involved and most often both arms are involved.  It would be very unlikely for elbow arthritis to be the first sign of rheumatoid arthritis.  Most of the time elbow arthritis starts to show up around age 50, and it seems to be much more common in men than women, although I see a fair number of women with elbow arthritis.

Elbow arthritis is usually easy to diagnose.  Usually with an exam and plain x-rays the physician can figure out if elbow pain and stiffness are due to arthritis or some other problem such as tendonitis.  In some cases an MRI or CT scan may be needed, usually to see if there are lose pieces of cartilage, or loose bodies in the joint.  Loose bodies would be suspected if the elbow was popping or clunking and the patient had the sensation that something was floating around inside of the joint.

Once the diagnosis is made then the question turns to treatment.  In early cases rest, ice, avoiding aggravating activities and over the counter non-steroidal medications such as Alleve or Advil are helpful.  If the pain gets bad enough a cortisone injection can be very helpful.  People start thinking about surgery if they are having problems with loose bodies and their elbows are locking up, if they are having enough stiffness that their elbow isn’t working well for them, or if the pain is starting to interfere with things they want to do.

There are a number of ways to treat elbow arthritis.  In milder cases elbow arthroscopy can be performed to remove loose bodies and small spurts from the elbow.  This seems to be a reasonable procedure to consider in very early cases.  If the stiffness is the main problem then sometimes the joint can be loosened up by releasing the scar tissue around the elbow and removing some of the spurs which are present.  There is a third procedure which is very successful at helping relieve elbow pain from arthritis.  It is called an ulno-humeral arthroplasty.  This surgery is based on the fact that the main spurs in elbow arthritis occur in the middle of the elbow.  A usually thin area of bone in the elbow gets really thick which makes the arthritis worse.  In the ulno-humeral arthroplasty the spurs in the back of the elbow are removed and the thick bone in the elbow is drilled out with a core drill.  The surgeon can then take out the spurs in the front of the elbow through the hole he just drilled and he can also often remove loose bodies as well.  This is a pretty big operation but I think it works well for a lot of patients.

When we talk about arthritis in other joints the conversation usually turns to joint replacements.  In the hip, knee and shoulder joint replacements have been found to be very effective in relieving pain and restoring motion to arthritic joints.  Unfortunately elbow replacements don’t seem to work as well.  In general elbow replacements are best done in patients with rheumatoid arthritis who don’t put too many demands on the arms.  Most surgeons recommend not lifting more than 5-10 pounds after an elbow replacement to decrease the chance of the elbow coming loose.  This is usually too much of a restriction for most people, so an elbow replacement for arthritis is usually a last resort where all the risks and benefits really need to be evaluated by the patient and the surgeon before going down this road.  I very rarely recommend an elbow replacement for patients with osteoarthritis of the elbow.

The good news about elbow arthritis is that it is pretty rare and usually doesn’t get so bad that patients need to have surgery.  The bad news is that if the arthritis is really bad, there are only a limited number of options available to take care of the problem.

 

Ouch! I broke my wrist! The distal radius

“I want to go home with the armadillo, good country music from Amarillo and Abilene.  The friendliest people and the prettiest women you’ve ever seen.”

“London Homesick Blues” written by Gary P. Nunn.

If you fall out onto your hand the most common bone that is broken is the radius.  Since the bone is distal, or away from the shoulder, this fracture is referred to as a distal radius fracture.  There is such a wide variety of fractures and patterns of fracture of the distal radius so that it’s hard to cover everything in one blog post, but since this is such a common injury it seems worthwhile to go over the common treatments and expected outcomes from this very common injury.

These fractures occur in people of all ages, from children to the elderly.  These fractures in children are a little different, so I’m going to focus on distal radius fractures in adults.  These fractures are very common in younger active adults and in the elderly but can occur in any age group.  Young adults can engage in high energy high risk activities (snowboarding is a great example) while older adults have softer bone and are prone to have the distal radius break after falling out onto their arm.  Regardless of the age group, these fractures occur in all shapes and sizes.  Sometimes there is just a simple crack in the bone, and little more than a brace or a cast is needed.  Other times the bone is shattered and requires extensive surgery by an expert to try and get the bone back together where it belongs.  What I would like to do is walk you through the thought process I go through when I evaluate a patient with a distal radius fracture and what treatment options I offer to patients.

The first order of business is to determine how “bad” the break is.  I look at the overall alignment of the fracture; that is, is it straight or not.  I also look at the wrist joint.  It’s important to have the joint lined up as close as possible to normal, so if the joint is out of place surgery is often needed to line the joint back up.  Third, I look at how many pieces the break is in.  Sometimes the bone is lined up okay, but if there are a lot of pieces (the medical term is comminution then the break may not stay in place and may require surgery to keep the bone lined up.

The second important factor is to assess the patient and their needs.  An elderly person who doesn’t mind a little bit of a crooked wrist can often function quite well with a distal radius fracture that doesn’t heal perfectly.  On the other hand a younger, active person almost always need perfect or near perfect alignment to have a good working wrist.  I don’t have any set age limit about when I’ll operate or not operate on patients with this fracture.  I have operated on patients over 80 because they needed to be able to take care of themselves or others.  I try to make sure I understand what each patient needs before recommending treatment.

So what are the options for treatment?  For simple fractures, which for me means the bone is straight, there’s not a lot of pieces, and the joint is lined up, most surgeons use a cast.  This can vary from 3 to 6 weeks depending on the surgeon.  In these cases I usually go for 2 to 3 weeks in a cast then switch to a removable brace.  It probably takes 3 to 4 months to regain strength and dexterity in the wrist.

The second scenario we see is a break that is out of place ( the medical term is displaced).  Some of these fractures can be reduced (a common term is be “set”).  If the bone goes back into place, the joint is lined up, and there aren’t too many fracture fragments, then the fracture can often be treated without surgery.  I like to keep a close eye on these fractures and get an x-ray about once a week for the first three weeks to make sure the bone isn’t slipping out of place.  Once again it usually requires about 6 weeks in a cast or brace for the bone to heal and 3 to 4 months, or even longer, for the patient to regain strength and motion in the wrist.

The third scenario involves fractures which usually require surgery.  These can be fractures that won’t go back in place, fractures that involve the joint surface, fractures with multiple fragments or any combination of the three factors above.  In these cases I usually recommend surgery.  Over the last 15 years some new plates have been developed allow us to restore alignment to the radius and keep the bone in place while it’s healing.  These plates have a good track record.  They usually don’t have to be removed, and most people aren’t bothered by the plates in their day to day activities.  Other surgeons use a combination of smaller plates and pins called “fragment specific fixation” and this seems to work very well.  In the past surgeons would put pins from the bone and connect them to a frame outside the wrist called an “external fixator”.  I think that overall the use of the external fixator is declining and probably most surgeons use them in severe open or compound injuries.  Some fractures involve the joint but are a single large piece and these can sometimes be fixed with screws only and not a plate.  After the surgery most patients only need a removable brace.  The recovery period is probably about the same as the fractures that we can treat without surgery.  This surgery has the usual risks of infection and possible bleeding complications, but fortunately these are rare.  There have been problems with tendons rupturing after this surgery.  This is not common but it’s something you need to be aware of when contemplating surgery.

I’ve found that the newer plates have really improved the outcome of treatment of patients with distal radius fractures.  Clearly not every fracture needs surgery, and not every patient needs surgery so it’s important to have a good discussion with your surgeon to make sure the treatment you both decide on is the best for you.

The scaphoid non-union

“When things start looking bad and it doesn’t look like your gonna make it that’s when you gotta get mean, I mean plumb mad dog mean.  Because if you give up and lose your head you neither win nor live, and that’s just the way it is”

Clint Eastwood from “The Outlaw Josey Wales”

The scaphoid is a small bone in the wrist that is very often broken or fractured during activities.  In a previous post I talked about the scaphoid, and ways to diagnose and treat a fractured scaphoid.  Unfortunately it is not all that uncommon for the scaphoid to fail to heal, which produces what surgeons call a non-union, or failure of the bone to heal. This is due to two main factors.  First, it is sometimes hard to tell if the scaphoid is broken or not, and if the break is not treated properly then the bone won’t heal and a non-union will develop.  Second, even if the break is diagnosed and treated properly, the bone can sometimes fail to heal despite proper treatment because of the tenuous blood supply to the bone.

Scaphoid fractures can be classified several ways, but one of the most common ways is to figure out in which part of the bone the scaphoid is broken.  Surgeons look at the scaphoid in thirds, with the distal third being nearest the fingers, the proximal third nearest the wrist, and the middle third in between.  This is important because the blood supply to the scaphoid comes into the bone in the distal and middle thirds.  The proximal third has a limited amount of blood going to it which makes breaks of the scaphoid in this area difficult to get to heal.

If the scaphoid bone has failed to heal, for whatever reason, then the surgeon has to evaluate several things.  First, as I mentioned above, is the location of the fracture.  Second is the size of the gap between the two bone ends.  This can effect the type of surgery needed to get the bone to heal.  And third, it’s important to have a good idea of the blood supply still getting to the bone, especially the proximal third of the bone.  A scaphoid non-union with poor blood flow to the proximal part of the bone can require a very different treatment from a non-union with a good blood supply.

The evaluation of a scaphoid non-union consists initially of x-rays.  Often these are the only tests needed and can provide the surgeon enough information to recommend proper treatment.  Sometimes a CT scan will be needed to show the extent of the non-union.  An MRI may be useful to evaluate the blood supply to the scaphoid.

Once enough information has been obtained to assess the non-union, several treatment options exist.  If there hasn’t been a long time between the time the bone was broken and the development of the non-union, and if the bone ends are close together, then an attempt can be made to avoid surgery and try a bone growth stimulator.  There are two kinds of bone growth stimulators.  One type uses ultrasound, and the other low dose electricity.  Both types seem to work reasonably well.  A cast may or may not be needed.  There are medical reports of healing rates up to 85%, so this is something to consider in the right patient.

If the non-union doesn’t look like it would heal with a bone growth stimulator then surgery is indicated to try and get the bone to heal.  There are a number of different options, but all of them require going in, scrapping out the area where the bone failed to heal, adding bone graft, then stabilizing the bone with screws or pins.  Bone graft is bone obtained from the patient.  In scaphoid surgery we can often use bone from the radius bone, which is right next to the scaphoid.  Sometimes we have to get bone from the pelvis, which I’ll describe in a minute.

There are a number of scenarios that might play out, and this is how I usually go about it.

  1.  Scaphoid non-union, good blood supply, and a small gap without collapse or movement of the scaphoid bone.  In this case I recommend going in and cleaning out the non-union, placing bone graft from the distal radius, and placing a screw in the bone.  I estimate this works 80-85% of the time.
  2. Scaphoid non-union, good blood supply, but a larger gap with collapse of the bone.  In this case I usually recommend getting a wedge of bone from the pelvis in order to strengthen and straighten out the scaphoid.  The bone can then be fixed with either pins or a screw.  This surgery works well but probably has closer to a 75% success rate.
  3. Scaphoid non-union, poor blood supply.  In these cases the bone grafting options above don’t work so well, so I will often do what is called a vascularized bone graft from the distal radius.  There are small arteries about the wrist the connect to areas of the distal radius, and a wedge of bone can be lifted up with the artery attached.  These procedures seem to work pretty well even if the scaphoid has poor blood supply, but I would guess that he success rate is the lowest of these three options, probably closer to 60%.
  4. Scaphoid non-union with arthritis.  If arthritis has already set in then it makes to sense to repair the scaphoid.  Instead, depending on the amount of arthritis, the scaphoid can actually be removed.

The goal of these surgeries is to get the scaphoid to heal and restore use and function to the patient.  It’s hard to get a “normal” wrist, mostly because of stiffness,  but getting the bone to heal can usually get people back to the activities they like to do.  The treatment of scaphoid non-unions is difficulty and requires a lot of patience and good decision making by the surgeon and the patient.

 

 

 

 

 

 

 

 

 

 

 

 

Oh no, I broke my wrist! The Scaphoid bone.

“What we got here is failure to communicate.  Some men you just can’t reach, so get what we had here last week.  Which is the way he wants it.  Well he gets it!”

Strother Martin as “The Captain” in the movie “Cool Hand Luke”

The wrist is a complicated area, with a large number of tendons and ligaments associated with a large number of bones.  The wrist consists of two large bones, the radius and the ulna, as well as eight smaller bones within the wrist itself.  The radius is the bone that is broken most commonly in the wrist, and of the smaller bones the one that breaks the most and causes the most trouble is the scaphoid.  I thought it would be worth some time to discuss fractures of the scaphoid and ways to diagnose and treat a broken scaphoid bone.  By the way, I will use the words “fracture” and “break” interchangeably.  They mean the same thing.

The scaphoid is located on the side of the wrist nearest the thumb.  If you hold your thumb up in the air like you are hitch-hiking you’ll see two tendons coming from the thumb back towards the elbow.  In between those two tendons is a small dip that is called the “anatomic snuffbox”:  this is where the scaphoid lives.  If you break your scaphoid this is where you will have the most tenderness and soreness.

By far the most common way the scaphoid is broken is to fall out onto your outstretched hand.  Sometimes the scaphoid can break during high intensity sports such as football without a clear mechanism.  The interesting thing is that the pain of a scaphoid fracture can be pretty minimal and can actually go away without the bone ever healing.  If you do hurt your wrist it’s also possible for an x-ray not to show the break initially.  This is due to the rather unique shape of the scaphoid.  The scaphoid is usually about an inch and a half long, round, with a curve to the bone.  Scaphoid means “boat” in Greek, but as one surgeon I heard giving a talk said “It doesn’t look like any boat I’ve ever seen.”  Because of this shape it can be hard for the x-ray beam to pass perpendicular  to the fracture line and show the break on an x-ray.  Because of these reasons people can break their scaphoid and never get treated for their injury.  Because the scaphoid has such a poor blood supply it usually doesn’t heal and can cause problems years down the road.

So first, let’s talk about how to diagnose a scaphoid fracture.  Let’s say you’ve fallen on your wrist, it hurts in the snuffbox area, and your x-rays don’t show a break.  There are two reasonable options at this stage.  You can wear a brace for 10-14 days and then get another x-ray.  Almost every scaphoid fracture with show up in this time frame and you can still make a treatment decision at that time.  If you didn’t want to wait then MRI has been shown to be the best way to diagnose a scaphoid fracture.  Either choice is reasonable and really depends on the patient and treating physician deciding to choose which way to proceed.

If the scaphoid is broken, then you usually have to make a decision whether to try and treat the broken bone with a cast or surgery.  First off, if there has been a delay in diagnosing the fracture, then surgery is almost always necessary.  If the fracture is recent, probably less than 6 weeks old or so, then you have to evaluate several factors to decide is surgery is needed.  One of these factors is the location of the fracture, that is, which part of the bone is broken.  The scaphoid runs from the wrist to the base of the thumb, and the end that is towards the thumb has a much better blood supply than the end that is near the wrist.   Fractures from the middle of the bone towards the thumb can heal pretty well with a cast, providing the fracture is not displaced or spread apart.  Fractures that are in the third of the bone closest to the wrist have a hard time healing with a cast and often require surgery.

The other factor to consider, which I mentioned early, is whether or not the fracture is displaced. In reality only fractures that are non-displaced (which means that there is a crack in the bone with no separation) can heal without surgery.

If your scaphoid fracture looks like it will heal without surgery, then wearing a cast in an option.  Most physicians use a short cast, below the elbow, with the thumb included in the cast.  Most fractures require a minimum of 6 weeks in a cast, and it can often take up to twice that long for the bone to heal properly.  Again, this is only a treatment available for acute, non-displaced fractures of the scaphoid.

For almost all other scaphoid fracture surgery is indicated.  An incision can be made on either the top or the bottom of the wrist and a screw can be placed across the break.  There are a number of headless screws available which can be placed inside the bone and won’t need to be removed.  The healing rate for both surgery and treatment with a cast are over 90%, which means that most but not all fractures will heal without any problems.

Another option for non-displaced scaphoid fractures is a placement of a screw over a pin placed through the skin.  This is called “percutaneous” screw fixation, and if a surgeon is experienced in this technique it is a safe and effective way to fix the scaphoid and avoid and extended period of time in a cast.  It’s important to discuss the pros and cons of these treatments with your physician to try and figure out what is the best solution for each person and their fracture.

So, what if your fracture was never diagnosed or didn’t heal after the initial treatment?  This is called a scaphoid non-union, and that will be the topic of my next post.

 

 

My wrist hurts! Pain on the radial side of the wrist

“The times they are a changin'”

Bob Dylan

Wrist pain is a very common problem and the symptoms generally seem to occur on one side of the wrist or the other.  In a previous blog I talked about pain on the ulnar side of the wrist, which is the side towards the little finger.  In this post I want to discuss pain on the radial side of the wrist which is the side that the thumb is on.

When the doctor listens to the patient describe pain we ask questions to try and pinpoint the source.  For instance, if your hand and wrist hurt and this is associated with numbness and tingling in the fingers, and the hand going asleep during activity and waking you up at night with numbness, then the most common cause is carpal tunnel syndrome, which I have discussed in other posts.  If the pain is associated with use and activity, then a diagnosis such as arthritis or tendonitis is more common.

On the radial side of the wrist there are specific areas of pain associated with specific areas of arthritis and tendonitis.  Since the thumb is so mobile and active, there are problems that actually both people most when they use their thumbs which are actually caused by issues at the wrist.  I’ll try to discuss these one at a time.

If the pain doesn’t seem to be affected by thumb movement then by far the most common cause of radial sided wrist pain is arthritis.  The wrist consists of eight different bones that connect with each other, and arthritis can occur in very specific areas.  The scaphoid bone sits on the radial side of the wrist and this is where the majority of wrist arthritis occurs.  The scaphoid can wear out at either end of the bone.  What happens is that ligaments stretch out and the cause the scaphoid to move outside of it’s normal range.  Over time this can cause the lining of the bone, or cartilage, to wear out.  Usually the first problem people have is that their wrist aches and the pain seems to get a little worse with activity.  Initially avoiding the aggravating activities and taking over the counter non-steroidals such as Alleve or Advil can take care of the problem.  If the arthritis worsens the wrist can start getting stiff and more painful.  Cortisone injections can help relieve the pain and sometimes improve wrist motion, at least for a period of time.  In some people the pain and stiffness get so severe that surgery is needed.  Unlike other joints such as the hip, knee and shoulder, where replacing the joint can be done very successfully, there is no real joint replacement for the wrist.  The surgery we usually recommend involves taking out the scaphoid, and either taking out a couple of other bones in the wrist or partially fusing some of the other wrist bones together.  These procedures are good at decreasing pain but patients usually only get about 50-60% of their wrist motion and their wrists are never quite as strong as a normal wrist.

Sometimes we find that that the scaphoid bone has broken and has never healed.  The injury can be something that happened quite some time ago and never bothered the patient too much.  The scaphoid, however, doesn’t have a very good blood supply and often won’t heal if the break wasn’t noticed or treated.  This can lead to pain and discomfort in the wrist that usually requires surgery.  I’ll discuss scaphoid fracture surgery in another post since that’s a pretty intense and complicated topic.

The other most common cause of radial sided wrist pain is known as DeQuervain’s tendonitis.  I’ve discussed DeQuervain’s in another post so you can look back at that post for a more detailed discussion.  The main thing that helps the doctor distinguish Dequervain’s from arthritis is that more pain occurs with movement of the thumb rather than the wrist but the pain is still located on the radial side of the wrist.  A lot of patients have swelling and some have a popping sensation with thumb movement.  The treatment usually involves rest and splinting.  Alleve and Advil can help, but some patients need either a cortisone injection or surgery if the problem gets bad enough.

The good news for patients is that most of the problems that cause pain on the radial side of the wrist can be helped and managed with simple treatments such as splinting and over the counter medications.  Cortisone shots and surgery can be used when the problems get so bad that they affect the things you do every day.

Wrist Pain: Why is my wrist hurting, Doc? The ulnar side of the wrist.

There are so many causes of wrist pain that it’s sometimes hard to decide where to start.  It would probably be best to define some terms so that we all know what we’re talking about.  There are two terms that are used to describe the location of problems around the wrist.  Hand surgeons use the words radial and ulnar to describe the areas where wrist problems occur.  These are named after the radius and ulnar bones, which are the two bones that connect the wrist to the elbow.  Radial refers to the side of the wrist  where the thumb is located, whereas ulnar refers to the side of the wrist where the little finger is.  There aren’t too many problems that involve both the radial and ulnar sides of the wrist so by splitting the wrist up into two sides we can usually get a better handle on what’s causing wrist pain.  This blog will deal with the ulnar side of the wrist, and next time I’ll go into common causes of radial sided wrist pain.

The most common cause of ulnar sided wrist pain that I see in my office is due to either irritation or tearing of a cartilage in the wrist.  This has the elegant name of the triangular fibrocartilage, or TFCC for short.  The TFCC is a cartilage that helps hold together the radius and ulnar bones at the wrist.  A number of other ligaments and tendons are involved in providing wrist stability, but the TFCC undergoes a lot of stress form normal day to day use of the hand and wrist.  The main stress on the cartilage is caused turning the hand over flat so that your palm faces the floor (known as pronation) and turning your palm up towards the ceiling (known as supination).  Since we’re constantly performing these actions, the TFCC undergoes a lot of stress, and as we age the cartilage can tear.  Most of the time a torn TFCC cartilage doesn’t cause any pain or problems but sometimes the cartilage gets irritated and starts to cause pain and swelling on the ulnar side of the wrist.  Some patients will have catching and popping in their wrists.  There is a soft spot on the ulnar side of the wrist between the ulna and the other wrist bones and this is where the TFCC is located.  That’s where people are tender when they have an irritated TFCC.  The good news is that most tears will calm down with rest, splinting, and non-steroidal anti inflammatory drugs such as Advil or Alleve.  If those conservative measures don’t work then cortisone shots can be very effective in getting rid of the pain and irritation.  In a small number of cases arthroscopic surgery can be performed to debride or clean out the cartilage.

Another common area of pain on the ulnar side of the wrist comes from a wrist tendon that runs right above the TFCC called the extensor carpi ulnaris tendon, or ECU for short.  The ECU runs in a sheath just over the TFCC and helps the TFCC hold the radius and ulna together at the wrist.  Thus the ECU is subject to much of the stress and strain that the TFCC is, and some people will actually have problems with both the TFCC and the ECU.  The ECU tendon can get irritated in it’s sheath and becomes inflamed and irritated.  The treatment of ECU tendonitis is basically the same as for the TFCC.  Rest. splints and medication can help, cortisone shots work pretty well, and for people who don’t get better surgery can be performed to clean out the tendon sheath.

The problems I’ve described are usually chronic in nature and occur without an specific injury such as a fall or car accident.  However both the TFCC and the ECU tendon can be damaged from a distinct, acute injury.  The acute injuries can also be treated by conservative means such as splints or cortisone injections, but it’s probably a little more common to have to have some sort of surgery in the acute situation.

There are other causes of wrist pain along the ulnar side of the wrist but they are much less common that the two we’ve already discussed.  People can develop growths such as ganglion cysts on the ulnar side of the wrist, but they are fairly rare.  In addition, a certain group of patients will have a situation where the ulna bone is a little longer than the radius bone at the wrist.  This can cause the ulna to bang into the wrist bones and cause many problems, including tearing the TFCC and some of the wrist ligaments.  This is called ulnar abutment syndrome and can often require surgery to clean out the wrist and shorten the ulna so it won’t keep causing problems.  A few patients will have arthritis where the radius and ulna meet, which usually causes catching and grinding in the wrist.

Most of the problems on the ulnar side of the wrist can be diagnosed through the history and and examination by the surgeon.  X-rays are usually needed to make sure there isn’t any arthritis or to see if there is evidence of ulnar abutment syndrome.  Occasionally an MRI is useful if the diagnosis isn’t clear from the history, exam and xrays.

Torn ligaments in the thumb: The Gamekeeper Thumb

“I’m sick, I’m weak, I’m tired and I’m torn.  I fell like I’m dying but I hardly been born”

from “Ode to Woody” by Bob Dylan performed by The Earl Scruggs Review

The thumb is the most important part of hand.  If you look at a disability chart that analyzes the value of each of our digits, the thumb is considered to be worth 50% of the hand, or equal to the value of all four fingers.  The thumb is an amazing digit.  It can move in multiple planes and allows us to do all sorts of different activities including grasping, pinching and even lifting.  The specialized function of the thumb makes an injury to the thumb even more of a problem than injuring the other fingers, and unfortunately injuries to the thumb are fairly common.  The thumb sticks away from the hand and can be injured in falls or accidents.  You can break a bone, rupture a tendon, or tear a ligament at different places in the thumb.

A ligament is a structure that holds two bones together at a joint.  Each joint in your hand usually has at least two ligaments, and some joints have even more.  The most commonly injured ligament in the thumb occurs at the metacarpal phalangeal joint.  This is the joint that moves up and down at the point where the thumb joins to your hand.  The joint on the inside of the thumb, the side that is towards the fingers, can be injured in a number of ways.  Snow skiers can get their thumbs caught in their ski poles or someone falling on their hand can get their thumb pulled away from the hand.  These injuries can stretch the ligament and sometimes tear the ligament completely.  The ligament is called the ulnar collateral ligament, and if the ligament is torn it is often called a “gamekeeper thumb.”

The name “gamekeeper thumb” originated in England.  It was actually used to describe a chronic stretching of the ligament which occurred in gamekeepers who had to kill wild hares by breaking their necks between the thumb and the hand.  This caused a chronic stretching of the ligament and usually caused pain and decreased use of the thumb.  Chronic injuries are not very common today, and most of the patients I see with “gamekeeper thumbs” have had some sort of accident such as a fall or were involved in a car accident.

Initially patients have pain and swelling on the inside of their thumb.  They usually have a sensation that something’s not right with their hand.  An x-ray needs to be taken to make sure the bone isn’t broken.  Sometimes instead of tearing the ligament will pull of a piece of bone.  If the x-rays don’t show a break, the next step is to test the joint to see how stable it is. In other words, does the joint move too much from side to side?  Sometimes this is very obvious to both the patient and the doctor, but sometimes it’s hard to tell if the ligament has been completely torn.  This is important because if the ligament if just partly torn it can heal with either a brace or a cast.  A completely torn ligament usually requires surgery.  If it’s not 100% clear if the ligament is torn then an MRI can tell you for sure.

If the ligament is completely torn, or if the ligament has pulled a piece of bone away then surgery is the best way to fix the thumb.  The ligament usually pulls away from one of the two bones rather than tearing in the middle, and at surgery the end of the tendon can be identified and reattached to the bone.  There are a number of ways to do this and I usually use a device call a suture anchor.  The company I use has a little metal corkscrew that you can put in the bone right where the ligament belongs.  The corkscrew has sutures attached to it and you can pull the ligament right back where it belongs.  If a piece of bone is pulled off you can sometimes put a small screw or wire, or you can use the corkscrew and suture the bone back in place.

After surgery it’s best to wear a splint or cast for around 6 weeks.  After that the thumb is usually pretty stiff but most patients get back a lot of their motion.  I think most people do pretty well with this surgery.  I’ve done this surgery on a couple of friends of mine and their thumbs have held up well for over 15 years.

The take home from this is that if you fall or hurt your thumb and something doesn’t feel right, there’s a good chance something is wrong and it’s a good idea to get it checked out by a physician.

I ruptured my biceps! What next?

“I may not be a smart man but I know what love is Jenny.”

from the movie “Forrest Gump”

One of the more common injuries that occurs around the elbow is to rupture the biceps tendon.  This is usually a very dramatic event that causes pain, swelling and bruising around the elbow.  For some reason this injury occurs almost solely in men.  I have never treated a biceps rupture in a women, and there are only a few cases of these found if you dig through the medical literature.

This injury usually occurs when someone is lifting a heavy object or lifting against a lot of resistance.  I’ve seen patients who ruptured their biceps while working out and doing curls, but most people are using their arm during normal activities and there is a sudden force on their arm which causes the rupture.  A lot of people hear a pop and they are usually aware that something significant has happened to their arm.  Most of the time the diagnosis is pretty obvious, and no tests other than an x-ray are needed.  Sometimes the diagnosis is not as clear and an MRI can show if a partial or complete tear has occurred.

The biceps muscle runs from the shoulder, down the front of the arm, and attaches on a bone in the forearm called the radius.  The muscle has two attachments at the shoulder (called the short head and the long head) and a single attachment just past the elbow.  Most people think of the biceps as the main muscle that flexes or bends the elbow.  Actually the muscle that does most of that work is under the biceps and is called the brachialis muscle.  The biceps attaches in such a way that the motion that it is responsible for is called supination.  The way to visualize this motion wound be to place your hand in front of you with the palm facing the floor.  The motion of turning your palm towards the ceiling is called supination.  The biceps comes into use with what doctors call “power supination”.  The best example of this would be to open a tight jar.

Although there is usually some pain and swelling with rupture of the biceps, this will eventually subside and go away.  The biggest problems people have when their biceps is ruptured is the associated weakness.  On average people lose over 40% of their supination power and up to 30% of their flexion power at the elbow and for the group of people who have this injury, which is mainly men in their 40’s and 50’s, that’s too much strength for them to give up.  Therefore most patients usually choose to have surgery to repair and reattach the tendon.

The goal of the surgery is to reattach the tendon back where it belongs but there are a number of ways to do this.  The surgery is difficult and it requires a good deal of knowledge about the anatomy around the elbow since several major nerves and arteries run close to the biceps.  If the surgery is done by an experienced surgeon then you can usually expect few complications and a good outcome.  Most patients regain all or almost all of their motion, and many patients regain all or most all of their strength.  The surgery can be done through one incision on the front of the elbow or through two separate incisions.  Each technique has it’s proponents and each technique has some unique complications associated with it.  I don’t think one technique is better than the other so it’s best to go with the one that your surgeon is most comfortable with.

It takes a long time to recover from this surgery.  The tendon doesn’t regain it’s normal strength for at least three months, and it is probably another 3 months or so before the whole are regains it’s normal strength.  There are new techniques that use small metal buttons to reattach the tendon, and so I’ve been letting patients use their arm earlier in their recovery than I used to, but I still urge people to be very cautious.

In general patients who have ruptured their biceps do well with surgery and regain a lot of their motion and strength.  If the patient lives a sedentary life and doesn’t need much strength, then it can make sense in a rare case not to repair the tendon.  This is a pretty hard surgery to do, so I would recommend that if you have ruptured your biceps tendon to seek out  a surgeon who has experience treating this injury.