The Anatomy of the Wrist

The wrist is a complex joint with two intricate rows of bones at the base of the hand. There are a total of eight small wrist (carpal) bones and five longer metacarpal bones, which support the fingers and thumb bones (phalanges). The ulna and the radius are the two long bones that form the forearm and these attach to the first row of the carpals. Each bone end is covered with cartilage, an elastic tissue that creates a cushioned smooth surface that allow the bones to glide smoothly against each other.

Wrist and Hand Arthritis

Arthritis comes in many forms, but the three main forms that affect the hand and wrist are osteoarthritis (OA) and rheumatoid arthritis (RA), and post-traumatic arthritis. Arthritis simply means joint inflammation, and usually causes pain, stiffness, and swelling of a particular joint, depending on the cause. Osteoarthritis is a progressive form of arthritis that destroys the smooth articular cartilage covering the ends of the bones and is generally known as “wear and tear” arthritis.

The cartilage wears away in this form of arthritis resulting in the well-known “bone on bone” pain of osteoarthritis. Rheumatoid arthritis is a chronic autoimmune disorder that affects multiple joints throughout the body. With RA, the arthritis is not limited to a particular joint of the hand or wrist, also involving inflammation of the tendons and ligaments, meaning these structures soften and erode which can lead to tearing of the tendons that are necessary to straighten the fingers. This results in a deformed joint with gnarled fingers and bent wrists.

Treatment for Wrist and Hand Arthritis

There are many treatments for wrist joint arthritis, depending on the location and severity of the condition.  Wrist bracing, activity modifications and over the counter pain medication such as ibuprofen and Tylenol are the first line of treatment. With wrist arthritis, there is often diagnostic and treatment value to an intra-articular steroid injection as many patients find months to years of relief with such treatments.

When symptoms persist despite these treatments, surgical management can be quite successful. The procedures for wrist arthritis include arthritis bone excision called a proximal row carpectomy, which requires no hardware.  Other patients benefit from partial wrist fusions depending on the location and cause of the arthritis. Still other patients eventually need a wrist fusion that limits the painful wrist flexion and extension that typically accompanies advanced wrist arthritis.

A newer type of treatment that I offer in select situations is a wrist replacement, known as wrist arthroplasty. The typical candidate for a wrist joint replacement is someone who has severe arthritis but doesn’t rely on the wrist for heavy daily use. I primarily perform this procedure to relieve pain and to maintain function of the hand and wrist.

Wrist replacement surgery will help recover and retain wrist movements and also will improve the ability to perform activities of daily living. During this procedure, the worn-out ends of the bones are removed and replaced with an artificial joint, which allows for smooth painless motion. This will help reduce or eliminate pain and improve grip strength. It is important to note that if the bones are fused together, the wrist will not be able to bend.

Wrist Joint Replacement Surgery

This procedure is done usually on an outpatient basis, but some patients require on overnight stay. An incision is made on the back of the wrist and the damaged ends of the arm bones are removed. Sometimes the first row of carpal bones must be removed also. Then, the prosthesis is inserted into the center joint region and held in place with a combination of screws and press fit that allows for bony in-growth.

After the surgery, a cast will be worn for several weeks. Once this is removed, a protective splint may be necessary for up to two months. I will prescribe pain relief medications and an exercise program to restore movement gradually by increasing power and endurance. Wrist arthroplasty often improves motion to around fifty to sixty percent of normal motion.

Carpal tunnel syndrome is a condition that causes weakness, pain, and numbness in the hand and wrist. My patients often describe worsening of symptoms when driving a car, reading the newspaper, or holding a telephone. These symptoms are also worse at night and often wake people up at night. This syndrome occurs because of increased pressure on the median nerve in the wrist. The pain of carpal tunnel syndrome occurs more often around the palm side of the wrist and hand and may radiate to the forearm, shoulder, and neck. The median nerve gives sensation to the fingers so many patients describe a tingling or numbness there. Many complain of dropping objects they pick up or difficulty buttoning buttons.

What is the Carpal Tunnel?

The carpal bones of the hand form a “C” shaped ring that is covered by a ligament. There are eight of these bones that vary in size and shape to make up the wrist area. This ligament and bony structures form the carpal tunnel through which the median nerve and nine tendons pass. These tendons flex the fingers and thumb. Any condition that affects the size of this tunnel can lead to carpal tunnel syndrome.

What Causes Carpal Tunnel Syndrome?

There are several factors that lead to carpal tunnel syndrome. Most commonly, it is thought that the syndrome is genetic, while repetitive, strenuous use of the hands often worsens the symptoms.  Other conditions that can cause or worsen carpal tunnel syndrome include fractures, masses, severe bruising. Conditions that are associated with carpal tunnel syndrome include hypothyroidism, infections, arthritis, pregnancy, and diabetes.

How is Carpal Tunnel Syndrome Treated?

The first line of treatment is non-operative. Wrist braces, activity modification and anti-inflammatories are usually the first step and can be helpful in many early cases. Surgery is often considered when you do not gain relief from these treatments. Worsening symptoms indicate a nerve at risk of permanent damage.

The decision is based mostly on the severity of your symptoms and your desire to return to normal functioning. In the most severe cases, surgery is done much sooner because the other treatment options are not likely to help. Also, long-standing cases often require surgery when the disease has resulted in constant numbness and wasting of the thumb and finger muscles.

Surgical Treatment

Carpal tunnel release surgery is one of the most common operations performed on the upper extremity and is among the safest and successful surgeries I perform. During the surgery, I will make a small cut in the palm of your hand. This will allow me to see the transverse carpal ligament of the carpal tunnel and divide this structure to increase the size of the tunnel and decrease the pressure placed on the median nerve.

Once this is done, I close the skin and the ligament will start to heal and grow across the divided area. This new growth actually heals the ligament and more space is available for the nerve and flexor tendons. Once this is done, the skin is sutured and a sterile bandage is applied. The sutures will need to be removed in seven to ten days.

The endoscopic method for carpal tunnel release allows me to visualize the ligament with a small camera and the procedure results in a more speedy recovery. Other benefits of this procedure are less postoperative pain, earlier return to work, and earlier return of grip strength.

What Should I Expect during Recovery?

Immediately following your carpal tunnel release surgery, you will be instructed to frequently elevate your hand above your heart and move your fingers as well. This is done to prevent stiffness and reduce swelling. There is some pain, swelling and stiffness to be expected after the surgical repair. The dressing is removed in 3-5 days and normal use of the hand is allowed once you are comfortable. Minor soreness of the palm region is common but reliably improves over time.

Arthroscopy

Arthroscopy is a common surgical procedure in which a joint is viewed by means of a small camera. The camera is inserted after the surgeon makes a small incision. The arthroscope allows the orthopedic specialist a clear view inside the knee to help diagnose and treat knee conditions.

Technological medical advances have afforded our surgeons high resolution cameras and high definition monitors. These and other advancements have made arthroscopic knee surgery an effective means for repairing damage to the knee and treating common knee problems.

What is involved with knee arthroscopy?

During an arthroscopic knee procedure, your orthopedic surgeon will insert a small camera instrument the size of a pencil into your knee joint. This device is called an arthroscope and it sends the image of the inside of your knee to the TV monitor the doctor watches.

On this monitor, he can see the knee structures in great detail. This allows him to feel, remove, and repair damaged tissues and structures.

How do I prepare for this surgery?

Be assured, almost all knee arthroscopies are done on an outpatient basis. If your doctor recommends a knee arthroscopy, you may need to undergo a complete physical examination with your family doctor prior to the surgery. He will check your health status and identify any problems that would interfere with the procedure.

Before surgery, you should tell the orthopedic specialist about any medications or supplements you are taking. He may tell you to stop taking these a few days before the procedure. You can expect that your surgeon will order some pre-operative tests before the surgery, too. These may include blood counts, X-Rays, and electrocardiogram (EKG).

What type of anesthesia will the surgeon use?

When you arrive to the outpatient surgery center, a member of the anesthesia team will want to speak with you. Knee arthroscopy can be done under regional or general anesthesia. While local anesthesia alone can be used for knee arthroscopy, it is not recommended because of more discomfort during the procedure and the lack of relaxation of the muscles during the procedure which you do get with regional or general anesthesia.

Regional anesthesia will numb you below your waist and general anesthesia puts you to sleep. The anesthesiologist will help you decide which type of anesthesia is best for you.

What can I expect during the procedure?

After you receive your anesthesia, the orthopedic specialist will make a few small incisions in your knee. Then, he will inject a sterile solution into the knee joint to rinse away any cloudy fluid that will obscure his view. First, the surgeon will introduce the arthroscope into the knee and use the TV monitor to guide him.

If your doctor sees that surgical repair is necessary, he will insert tiny instruments through other small incisions to do this. These could include scissors, graspers, and motorized shavers. Overall, the procedure generally lasts around 30 minutes to an hour. How long it takes really depends on what the surgeon finds and the treatment that is necessary.

Your surgeon will close your incisions with stitches or Steri-Strips and cover them with a dry, clean bandage. You will be moved to a recovery area for about an hour before being released. You will need to have someone there to drive you home.

Knee arthroscopy is most commonly used for:

• Removal or repair of torn meniscal cartilage
• Removal of loose fragments of bone or cartilage
• Reconstruction of a torn anterior cruciate ligament
• Trimming of torn pieces of articular cartilage
• Removal of inflamed synovial tissue

What can I expect during the recovery period?

You will recover from arthroscopic knee surgery quicker than from traditional open knee surgery. It is very important for you to follow your orthopedic surgeon’s instructions carefully after you go home.

Dressing Care – When you leave the hospital, you will have a dressing covering your knee. Be sure to keep this clean and dry. Your surgeon will tell you when it is alright to bathe or shower and when and how to change the dressing. Don’t remove the stitches or Steri-Strips.

Swelling – Keep your leg elevated as much as possible for the first couple of days after your arthroscopic knee procedure. You can apply ice as recommended by your doctor to relieve pain and swelling.
Bearing Weight – Most patients will not need crutches or a cane after knee arthroscopy. Your orthopedic specialist will tell you when you are to put weight onto the leg and foot.
Driving – Your doctor will tell you when you may drive. This decision will be based on several things, including your level of pain, the nature of your procedure, the knee that is involved, whether you have a stick shift or automatic car, and how well you can control your knee.

Generally, patients can drive within a few days after this procedure.
Medications – Your doctor will give you medications to help relieve discomfort following your knee arthroscopic procedure. Sometimes, a medication like aspirin is recommended to lessen your risk of blood clots.

What exercises can I do to strengthen my knee?

Your doctor will recommend an exercise program for you following your arthroscopic knee surgery. This is done to restore motion and strengthen the muscles of your knee and leg. Therapeutic exercises are important for a speedy recovery. Sometimes, the surgeon finds it necessary to set you up for formal physical therapy to improve your final result.

When can I get back to my normal routine?

Typically, you are able to return to your normal physical activities within 4 to 8 weeks. Higher impact activities, such as running and aerobics, may need to be avoided for a longer periods of time. You will need to discuss this with your orthopedic specialist to make sure you don’t further damage your knee joint.

The final outcome of your surgery is largely determined by the degree of damage to your knee.

Many athletes develop shin splints, a condition called tibial stress syndrome by doctors. Whether you are running a marathon or just sprinting to catch the bus, you feel a throbbing or aching in your shins and that’s shin splints.

Shin splints are not a real medical condition but a symptom of an underlying problem.

This symptom could be the result of irritated and swollen muscles from overuse, stress fractures (tiny hairline breaks in the lower leg bones), over pronation from flat feet causing the arch of the foot to collapse and stretching of the muscles and tendons to occur. … read more