I see many wrist fractures, these are among the most common along with symptoms and treatment.

Distal Radius Fracture

The most commonly broken wrist bone with a fall on an outstretched hand is a break of the distal radius. The radius is the larger of the two forearm bones and the end toward the wrist is called the distal end. When the area of the radius near the wrist breaks it is considered to be a fracture of the distal radius. Distal radius fractures are very common.

Symptoms of a distal radius fracture are immediate pain, bruising, swelling, and tenderness. Often times the wrist hangs in an odd or bent way, otherwise known as a deformity.

What are the risk factors for a distal radius fracture?
Osteoporosis is a risk factor for all types of fractures, especially a distal radius fracture. A broken wrist can happen in healthy bones as well. The majority of these types of fractures occur in people older than 60 years of age who fall from a standing position. The other subset of people who injure their wrist are young patients with a high impact fall, causing a break in an otherwise normal wrist.

How is a distal radius fracture treated without surgery?
Treatment for a distal radius fracture involves the nature of the fracture, the age and activity level of the person injured, and the orthopedic specialist’s personal preferences. The doctor can cast the broken bone if it is in good position and is stable. Sometimes the orthopedic specialist must straighten the bone (reduce it) before a cast is applied. This is what doctor’s call a closed reduction. The cast is usually worn for about 6 weeks and at that time the doctor could order physical therapy to help with rehabilitation.

What is involved in surgical treatment?
There are times when distal radius fractures result in the bone being so much out of place that it cannot be corrected without surgery. The orthopedic surgeon will make an incision to directly access the broken bones to improve alignment. The bone can be held in correct position with the use of a plate and screws, metal pins, an external fixator or any combination of techniques.

Scaphoid Fracture of the Wrist

The scaphoid bone is one of the small bones in the wrist, and it is the wrist bone that is most likely to break. It is located on the thumb side of the wrist in the area where the wrist bends. It can be easily located when the thumb is held in a “hitch-hiking” position. The scaphoid bone is at the base of the hollow made by the thumb tendons.

Symptoms it is fractured include pain, swelling, and tenderness at the base of the thumb. The pain will worsen when the person grips something or tries to move the thumb or wrist. A scaphoid fracture is usually caused by a fall onto an outstretched hand and is not always as painful as one might think.

What are the risk factors for a scaphoid fracture?
Anyone can fracture their scaphoid bone but it is more common in athletes who participate in activities where falls are common. Men aged 20 to 30 are most likely to experience this type of injury.

How is a scaphoid fracture treated without surgery?
If the bone is in proper position and has good blood supply, the orthopedic specialist may treat it by casting. The cast is usually worn for 12 weeks. Many opt for surgical stabilization to minimize the length of immobility.

What is involved in surgical treatment?
Due to the precarious nature of the blood supply to the scaphoid, the orthopedic specialist may recommend surgery to optimize healing and prevent long term wrist arthritis. During the procedure metal implants (such as screws and wires) are used to hold the scaphoid in place until the bone is completely healed. The surgeon makes an incision over the front or the back of the wrist to align the bone, insert the metal implants, and repair the damage.

In special situations where the bone is not healing well on its own, a bone graft may be needed to aid in healing. A bone graft is new bone that is place around the broken bone to help stimulate bone healing. This allows the bone pieces to heal together into a solid bone.

Knee replacement surgery is also known as knee arthroplasty. This is a procedure that can help relieve pain of the knee and restore function of the knee joint. The knees develop osteoarthritis and other disorders that prevent them from bending appropriately.

During this knee surgery, the surgeon will remove damaged bone and cartilage from the thighbone, shinbone, kneecap, and surrounding areas and replace what is removed with an artificial prosthetic joint.

Today there are many good alternatives to the old crude hinges of yesteryear. You can have a metal alloy knee or one made with high-grade plastic and polymer. The surgeon performing knee replacement surgery in Seattle will decide which one is best for you based on your age, activity level, weight, and overall health.

What is arthritis?

Arthritis is means “inflammation of the joint.” Most people think of arthritis as the wearing away of joint cartilage. This causes severe inflammation and pain within the joint. When most of this cartilage is lost and the bone is exposed, we consider this osteoarthritis.

It is the “wear-and-tear” that occurs with age or athletic activities. Other types of arthritis are rheumatoid arthritis (a more severe type), gouty arthritis (more painful and less common), and lupus arthritis (uncommon).

What are the risks of knee replacement arthroplasty?

The risks of a knee replacement include: infection, knee stiffness, heart attack, stroke, nerve damage, or blood clots in the leg vein or lungs. Only around 2 percent of those undergoing this procedure will have serious complications, according to the American Association of Orthopedic Surgeons.

Who is a candidate for a knee replacement?

The most frequent reason for knee replacement surgery in Seattle is for the repair of joint damage caused by osteoarthritis and rheumatoid arthritis. You may be an applicant for knee replacement if:

– You have disabling pain. Individuals who need knee replacement surgery commonly have problems walking, stooping, climbing stairs, and getting in and out of chairs. These people also experience moderate or severe knee pain at rest. Surgery may be an option in this case.

– You have a knee deformity. Knee replacement surgery can be particularly helpful for people who have a knee that bows in or out or one that has lost function and shape from rheumatoid arthritis.

– You’re 55 or older. Knee replacement is normally performed in older adults, but it may be considered for adults of any ages. Young physically active people are more likely to wear out their new knees prematurely, so doctors try not to replace young knee joints.

– You have failed on other treatments. More conservative treatments are weight loss, physical therapy, a cane or other walker, medications, and braces. If these don’t help you, you may be a candidate for a knee replacement.

– Your general health is good. Conditions such as restricted blood flow, cardiovascular disease, diabetes, serious lung disease, cancer, or infections can complicate surgery and recovery. The ideal candidate will not be in poor health.

What are the alternatives to knee replacement surgery?

Knee replacement is typically reserved for patients who have tried all of the other treatments and failed with them. Some of these individuals are still left with significant pain during normal activities, regardless of what medication or treatment they have taken.

Patients who only have occasional pain, are who are able to participate in athletic activities may not need a knee replacement. Others who have not tried non-operative treatments are probably not ready for a knee arthroplasty, either.

Non-operative treatment options include: arthrocentesis, arthroscopy, cortisone injections, Synavisc injections, physical therapy, heat therapy, massage therapy, cartilage transplantation, specialized knee braces, and arthrodesis with knee fusion, weight loss, and oral medications.

What are the Contraindications of knee arthroplasty?

There are a few reasons your doctor would not want you to undergo knee replacement surgery in Seattle. These include but are not limited to: knee sepsis, severe vascular disease, recurvatum deformity with muscle weakness, extensor mechanism dysfunction, a remote source of ongoing infection, and the presence of a well-functioning joint.

There are also relative contraindications where the medical condition doesn’t make the procedure safe or effective. These include: obesity, neuropathic joint, past history of osteomyelitis of the knee, and skin conditions that affect the knee (like psoriasis).

Remember, total knee replacement is an elective and life-enhancing surgery. It is not a life-saving surgery. The decision to undergo total knee surgery is one you must make once you are informed and well-educated on the alternatives, risks, and complications. It is important that you be aware of your options and be realistic with your expectations.

Description
Ulnar nerve entrapment occurs when one of the nerves in the arm (the ulnar nerve) becomes compressed and can’t function normally. This can give symptoms of “falling asleep” in the ring finger and little finger, especially when the elbow is bent. You may have aching pain on the inside of the elbow.

In some cases, you may have trouble moving the fingers in and out, or manipulating objects. Carpal tunnel syndrome has similar symptoms but involves a different nerve (the median nerve). Carpal tunnel syndrome typically causes tingling in the thumb, index finger and long finger.

The ulnar nerve is one of the three main nerves in the arm. It travels from under the collarbone and along the inside of the upper arm. It passes through a tunnel (the cubital tunnel) behind the inside of the elbow. Here you can feel the nerve through the skin. It is commonly called the “funny bone.”

Beyond the elbow, the nerve travels under muscles on the inside of the arm, and into the hand on the pinky side of the palm. When the nerve goes into the hand, it travels through another tunnel (Guyon’s canal). The most common place where the nerve gets compressed is behind the elbow. Sometimes it gets compressed at the wrist, beneath the collarbone, or as it comes out of the spinal cord in the neck.

The nerve functions to give sensation to the little finger and the half of the ring finger that is near the little finger. It also controls most of the little muscles in the hand that help with fine movements, and some of the bigger muscles in the forearm that help to make a strong grip.

Risk Factors/Prevention
It is not known exactly what causes compression of the ulnar nerve. Some factors can make it more likely that the nerve will be compressed. These include prior fractures of the elbow, bone spurs, swelling of the elbow joint, or cysts. A direct blow to the inside of the elbow, leaning on the elbow for prolonged periods, or repetitive activity that requires a bent elbow can irritate the nerve if it is already compressed. If the ulnar nerve is compressed at the wrist, the cause is more likely to be a cyst in Guyon’s canal.

Symptoms
Numbness and tingling in the ring finger and little finger are common symptoms of ulnar nerve entrapment. Often these symptoms come and go. They happen more often when the elbow is bent, such as when you are driving or talking on the phone. Some people wake up at night because their fingers are numb. You may also have weakness of grip and difficulty with finger coordination (such as typing or playing an instrument). If the nerve is very compressed or has been compressed for a long time, muscle wasting in the hand can occur. Once this happens, muscle wasting cannot be reversed. For this reason, it is important to see the doctor as soon as you experience any of the symptoms.

Diagnosis
Always see an orthopaedist if you are having symptoms of ulnar nerve entrapment that interfere with normal activities or last more than a few weeks.
The doctor will examine the arm to check the nerve, and try to determine where the nerve is compressed. If the nerve is irritated, tapping over the nerve at the “funny bone” can cause a shock into the little finger and ring finger, although this can happen when the nerve is normal as well. The doctor will probably move the shoulder, elbow and wrist to see if any of these cause symptoms. The doctor will test the sensation in the fingers.

Although most causes of compression of the ulnar nerve cannot be seen on X-ray, the doctor may take an X-ray of the elbow or wrist to look for bone spurs, arthritis or other places that the bone may be compressing the nerve. If the doctor thinks that the nerve is compressed at the wrist, a CT scan (computed tomography) or MRI (magnetic resonance image) may be recommended to see if a cyst or other structure is the cause of the compression.

The doctor may recommend nerve conduction studies. These are special tests to determine how well the nerve is working and to help localize the area of compression. Nerves work like wires; when the nerve is not working well, it takes too long for the nerve to conduct. During this test, the nerve is stimulated in one place; the amount of time it takes for the response to be conducted to another place is determined. The area where the nerve conduction takes too long is likely to be the place where the nerve is compressed. Sometimes, a small needle is put into some of the muscles that the ulnar nerve controls. This can determine if there is any evidence of muscle wasting.

Treatment Options
Unless you have a lot of muscle wasting, your doctor will probably recommend nonsurgical treatment initially. The following treatments may help to improve the symptoms. They may be all the treatment you need.

• Avoid frequent use of the arm with the elbow bent. If you use a computer frequently, make sure that your chair is not too low. Do not rest the elbow on the armrest.
• Avoid leaning on the elbow or putting pressure on the inside of the arm. For example, do not drive with the arm resting on the open window.
• Keep the elbow straight at night when you are sleeping. This can be done by wrapping a towel around the straight elbow, wearing an elbow pad backwards, or using a special brace.

If symptoms are acute, the doctor may recommend that you take an anti-inflammatory medicine such as ibuprofen to help reduce swelling around the nerve. Steroid (cortisone) injections around the ulnar nerve are not generally used because there is a risk of damage to the nerve.

Some doctors think that exercises to help the nerve slide through the tunnels can improve the symptoms. These exercises can help keep the arm and wrist from getting stiff.

Treatment Options: Surgical
If you are not improving with the strategies listed above, if the nerve is very compressed, or if you have muscle wasting, the doctor may recommend surgery to take pressure off of the nerve. Most often, the surgery is done around the elbow, but it can be done at the wrist if that is the place of the compression. Sometimes, the nerve is compressed in both places, so surgery is done at both the elbow and the wrist.

Surgeons use various ways to relieve compression from the nerve around the elbow. All of the operations involve making an incision around the elbow. In one operation, only the “roof” is taken off of the cubital tunnel. This tends to work best when the nerve compression is mild. More commonly, the nerve is moved from its place behind the elbow to a new place in front of the elbow. This is called an anterior transposition of the ulnar nerve. The nerve can be moved to lie under the skin and fat but on top of the muscle (subcutaneous transposition), within the muscle (intermuscular transposition) or under the muscle (submuscular transposition). There are many factors that go into deciding where the nerve is moved. The doctor will recommend the best option for you.

If the nerve is compressed at the wrist, a zigzag incision will be made at the base of the palm on the pinky side. The surgeon will open the roof of Guyon’s canal to take the pressure off the ulnar nerve. If there is a cyst or another reason for the compression, the surgeon will remove that at the same time.
The surgery is usually done on an outpatient basis or with an overnight stay in the hospital. Depending on the type of surgery, you may need to wear a splint for a few weeks after the operation. A submuscular transposition usually requires a longer time (3-6 weeks) in a splint. The surgeon may recommend physical therapy to help you regain strength and motion in the arm.

The results of the surgery are generally good. If the nerve is very badly compressed or if you have muscle wasting, the nerve may not be able to get back to normal and you may have some symptoms even after the surgery. Nerves recover slowly, and it can take a long time to know how well the nerve will do after the operation.

Description
Tennis elbow is a degenerative condition of the tendon fibers that attach on the bony prominence (epicondyle) on the outside (lateral side) of the elbow. The tendons involved are responsible for anchoring the muscles that extend or lift the wrist and hand (see Figure 1).

Risk Factors/Prevention
Tennis elbow happens mostly in patients between the ages of 30 years to 50 years. It can occur in any age group. Tennis elbow can affect as many as half of athletes in racquet sports. However, most patients with tennis elbow are not active in racquet sports. Most of the time, there is not a specific traumatic injury before symptoms start. Many individuals with tennis elbow are involved in work or recreational activities that require repetitive and vigorous use of the forearm muscles (see Table 1). Some patients develop tennis elbow without any specific recognizable activity leading to symptoms.

Symptoms
Patients often complain of severe, burning pain on the outside part of the elbow. In most cases, the pain starts in a mild and slow fashion. It gradually worsens over weeks or months. The pain can be made worse by pressing on the outside part of the elbow or by gripping or lifting objects. Lifting even very light objects (such as a small book or a cup of coffee) can lead to significant discomfort. In more severe cases, pain can occur with simple motion of the elbow joint. Pain can radiate to the forearm.
To diagnose tennis elbow, tell the doctor your complete medical history. He or she will perform a physical examination.

• The doctor may press directly on the bony prominence on the outside part of the elbow to see if it causes pain.
• The doctor may also ask you to lift the wrist or fingers against pressure to see if that causes pain.

X-rays are not necessary. Rarely, MRI (magnetic resonance imaging) scans may be used to show changes in the tendon at the site of attachment onto the bone.

Treatment Options
In most cases, nonoperative treatment should be tried before surgery. Pain relief is the main goal in the first phase of treatment. The doctor may tell you to stop any activities that cause symptoms. You may need to apply ice to the outside part of the elbow. You may need to take acetaminophen or an anti-inflammatory medication for pain relief.
Orthotics can help diminish symptoms of tennis elbow. The doctor may want you to use counterforce braces and wrist splints. These can reduce symptoms by resting the muscles and tendons (see Figure 2).

Symptoms should improve significantly within four weeks to six weeks. If not, the next step is a corticosteroid injection around the outside of the elbow. This can be very helpful in reducing pain. Corticosteroids are relatively safe medications. Most of their side effects (i.e., further degeneration of the tendon and wasting of the fatty tissue below the skin) occur after multiple injections. Avoid repeated injections (more than two or three in a specific site).

After pain is relieved, the next phase of treatment starts. Modifying activities can help make sure that symptoms do not come back. The doctor may want you to do physical therapy. This may include stretching and range of motion exercises and gradual strengthening of the affected muscles and tendons (see Figure 3). Physical therapy can help complete recovery and give you back a painless and normally functioning elbow. Nonoperative treatment is successful in approximately 85 percent to 90 percent of patients with tennis elbow.

Treatment Options: Surgical
Surgery is considered only in patients who have incapacitating pain that does not get better after at least six months of nonoperative treatment.
The surgical procedure involves removing diseased tendon tissue and reattaching normal tendon tissue to bone (see Figure 4). The procedure is an outpatient surgery; you do not need to stay in the hospital overnight. It can be performed under regional or general anesthesia.

Technique for surgical treatment of lateral epicondylitis. A, Skin incision over the lateral epicondyle. B, Distal reflection of the extensor mechanism exposing the lateral compartment of the elbow. C, Excision of pathologic tissue from the underside of the extensor mechanism. D, Decortication of the lateral epicondyle. E, Drilling of two V-shaped tunnels within the lateral epicondyle. F, Reattachment of the extensor mechanism to the lateral epicondyle. G, Side-to-side repair of the extensor tendon mechanism.

Most commonly, the surgery is performed through a small incision over the bony prominence on the outside of the elbow. Recently, an arthroscopic surgery method has been developed.

So far, no significant benefits have been found to using the arthroscopic method over the more traditional open incision.

After surgery, the elbow is placed in a small brace and the patient is sent home. About one week later, the sutures and splint are removed. Then exercises are started to stretch the elbow and restore range of motion. Light, gradual strengthening exercises are started two months after surgery. The doctor will tell you when you can return to athletic activity. This is usually approximately four months to six months after surgery. Tennis elbow surgery is considered successful in approximately 90 percent of patients.

Description
Osteoarthritis occurs when the cartilage surface of the elbow is damaged or becomes worn. This can happen because of a previous injury such as elbow dislocation or fracture. It may occur due to degeneration of the joint cartilage from age. Osteoarthritis usually affects the weightbearing joints, such as the hip and knee. The elbow is one of the least affected joints due to its well matched joint surfaces and strong stabilizing ligaments. This makes the joint able to tolerate large forces across it without becoming unstable.

A doctor can usually diagnose elbow arthritis based upon a patient’s symptoms and standard X-rays (Figure 1). X-rays show the arthritic changes. Most of the time, advanced imaging studies such as CT (computed tomography) or MRI (magnetic resonance imaging) scans are not needed. Elbow osteoarthritis that occurs without previous injury is more common in men than women. It usually begins after age 50, although some patients can have symptoms earlier.

Risk Factors/Prevention
Most patients who are diagnosed with elbow osteoarthritis have a history of injury to the elbow, such as a fracture that involved the surface of the joint, or an elbow dislocation.

The risk for elbow arthritis increases if:

• The patient needed surgery to repair the injury or reconstruct the joint
• There is loss of joint cartilage
• The joint surface cannot be repaired or reconstructed to its pre-injury level

Injury to the ligaments resulting in an unstable elbow can also lead to arthritis, even if the elbow surface is not damaged. That’s because the normal forces across the elbow are altered, causing the joint to wear out more rapidly.

Sometimes there is no single injury. Work or outside activities may also lead to elbow arthritis if the patient places more demands on the joint than it can bear.

For example, professional baseball pitchers place unusually high demands on their throwing elbows. This can lead to failure of the stabilizing ligaments. It usually needs surgical reconstruction. High shear forces placed across the joint can lead to cartilage breakdown over a period of years.

The best way to prevent elbow arthritis is to avoid injury to the joint. When injury does happen, it is important to recognize it right away and get treatment. Individuals involved in heavy work or sports activities should maintain muscular strength around the elbow. Always use proper conditioning and technique.

Symptoms

The most common symptoms of elbow arthritis are:

• Pain
• Loss of range of motion

You might not have both symptoms at once. Patients usually complain of a “grating” or “locking” sensation in the elbow. The “grating” is due to loss of the normal smooth joint surface. This is caused by cartilage damage or wear. The “locking” is caused by loose pieces of cartilage or bone. These can dislodge from the joint and become trapped between the moving joint surfaces, blocking motion.

Joint swelling may also occur. But this does not usually happen at first. Swelling occurs later, as the disease progresses.

In later stages, patients might also notice numbness in their ring finger and small finger. This can be caused by elbow swelling or limited range of motion in the joint. The “funny bone” (ulnar nerve) is located in a tight tunnel behind the inner (medial) side of the elbow. Swelling in the elbow joint can put increased pressure on the nerve. This causes tingling. If the elbow cannot be moved through its normal range of motion, it may stiffen into a position where it is bent (flexion). This can also cause pressure around the nerve to increase.

Treatment Options
Treatment options depend on the stage of the disease, prior history, what the patient desires, overall medical condition, and the results of X-rays.

For the early stages, the most common treatment is non-surgical. This includes oral medications such as Tylenol® or Advil®, physical therapy, activity modification and joint injections.
Sometimes corticosteroid injections are used to treat arthritis symptoms. Steroid medication has typically been used with good results. The affects are temporary. But injections may give significant relief until symptoms progress enough to need additional treatment. An alternative to steroids has been the injection of hyaluronic acid in various forms. This attempts to increase the fluid in a joint, a process called viscosupplementation. It surrounds the diseased cartilage with a thicker and more “cushioned” environment.

This treatment has been recently studied in people with osteoarthritis of the knee. While there was enthusiasm for this treatment, research has not shown it to be better than traditional steroid injections. Additionally, the hyaluronic injections were significantly more expensive. The results of these “viscosupplementation” injections in the elbow or other joints have not been investigated.

When nonsurgical interventions are not enough to control symptoms, surgery may be needed.

Treatment Options: Surgical
By the time arthritis can be seen on X-rays, there has been significant wear or damage to the joint surfaces. If the wear or damage is limited, arthroscopy can offer a minimally invasive surgical treatment. It may be an option for patients with earlier stages of arthritis.

Arthroscopy has been shown to provide symptom improvement at least in the short term. It involves removing any loose bodies or inflammatory/degenerative tissue in the joint. It also attempts to smooth out irregular surfaces. Multiple small incisions are used to complete the surgery. It can be performed as an outpatient procedure. The recovery is reasonably rapid.

If the joint surface has worn away completely it is unlikely that anything other than a joint replacement would bring about relief. There are several different types of joint replacement available (Figure 2).

In appropriately selected patients, the improvement in pain and function can be dramatic. With an experienced surgeon, the results of elbow replacement are the same as the results of hip replacement and knee replacement. For patients who are too young or who are too active to have prosthetic joint replacement, there are other reasonably good options.

If loss of motion is the primary symptom, the surgeon can release the contracture and smooth out the joint surface. At times, a new surface made from the patient’s own body tissues can be made. These procedures can give years of symptom improvement.

Research on the Horizon/What’s New?
Recently, joint supplementation has been used as an alternative to traditional oral and injectable medication. For oral medication, this involves a glucosamine/chondroitin supplement. These “nutraceuticals” attempt to give the body more of the basic elements that make up cartilage. Then the body may attempt to maintain or “build back” cartilage. There have been few well-controlled research studies on glucosamine/chondroitin. They have not included patients with elbow arthritis. So the short and long term effects are not yet known. Anecdotal reports have been favorable.

In cases where there has been loss or damage to areas of the joint, a cartilage/bone graft can be considered. This procedure attempts to return the joint to its prior smooth appearance and form in an attempt to prevent further deterioration of the joint. As our understanding of cartilage growth and regeneration improves, this may allow replacement of larger areas of joint damage or degeneration. Newer elbow replacements have also been designed with the goals of greater longevity and easier insertion compared with prior designs.